Resident education and training: Preparing our residents for the road ahead

Resident education has been fairly stable for the past few decades. However, we have experienced dramatic changes in the past 3 years, which have completely changed the playing field and the “look” of orthopedic surgery residency programs.

This Orthopedics Today Round Table brings together thought leaders in residency education and gets their views on these exciting and yet non-validated changes. The panel includes some seasoned veterans who have “seen it all” as well as younger innovators and educators who are leading the charge in resident education. I hope readers find it fascinating as we embark upon a new pathway in the education of orthopedic surgery residents.

William N. Levine, MD
Moderator

William N. Levine, MD: Beginning in 2011, changes in PGY-1 rules and regulations led to the elimination of in-house call and rotations without “direct supervision,” and called for work shifts not exceeding 16 hours. How have the changes affected your program? Have you noted a difference in this year’s PGY-2 classes in their preparation, skill level, confidence and competency since they are the first group to have lived through these changes?

Kevin P. Black, MD: I have not noticed any difference in the level of preparation or confidence of our PGY-2 residents. We need to think about the other variables that can have an impact, including changes in curriculum. I think our PGY-1 residents may have received more instruction from their senior residents, so it may be that they were better prepared. It comes down to the quality of the learning experiences in the PGY-1 year more than the number of hours.

Jonathan P. Braman, MD: The biggest role of the intern year was learning to manage complex information, varied medical situations, and to formulate and communicate plans with other team members. I believe shortening the intern workday and severely limiting overall exposure to medical work during the internship has changed this role significantly. While most orthopedic residents will still develop the necessary skills to prepare for the PGY-2 year, there is an increased risk of residents struggling in these content domains. While it is too early to know if this is a real trend, since the change, I have seen more residents who as PGY-2 residents still present cases like MS-4 students. Some PGY-2 residents are still having trouble managing the work of orthopedics (clinic dictations, operative work, call work and discharge work) all of which used to be learned early in an internship.

The intern year was the year for development of basic surgical skills. Most basic surgical skills can be taught in other environments – and arguably should be taught outside of clinical care. However, since adequate self-directed curricula do not exist at this time, it takes significant faculty non-clinical teaching time to properly educate residents in these skills. The educational system is already taxed by reductions in support from the federal government and hospitals for graduate medical education. The additional need for more faculty time to “teach” outside of the clinical setting is only going to increase these pressures.

Kenneth A. Egol, MD: As with most of the changes instituted by the Accreditation Council for Graduate Medical Education (ACGME) with regard to work hours, the limitations imposed on interns is similarly misguided in my opinion. While the intent is understandable, a “one-stop shopping” approach to all disciplines is mistaken. Surgical specialties often require longitudinal follow-up to gain exposure to the natural history of the most of acute surgical conditions. As such, these changes have taken interns away from the team aspect of patient care and made them shift workers, who bounce in and out of patient care scenarios, getting partial views of multiple experiences.

With that being said, I have not seen an improvement or any detriment to their performance as of yet, although we are only 2 months into the year. That is likely because we have marginalized their importance in the system. Generally, with the addition of physician extenders throughout the hospital system on all surgical services, the need for an “intern” presence has been diminished. One positive aspect of the fewer hours worked during the intern year has been the ability of trainees to spend more time reading orthopedics and attending conferences.

Thanks to the Council of Orthopaedic Surgery Residency Directors, working with the orthopedic Residency Review Committee (RRC), the changes instituted this year for orthopedic interns will have a positive impact. Working fewer hours during the PGY-1 year is certainly tempered by the increase in orthopedic experience that has occurred with the newest changes in PGY-1 workload. Moving from 6 months of general surgery to 6 months of orthopedic surgery services is an immensely positive step.

With respect to the changes to the PGY-1 year, most aspects have been positive. While these changes have been positive with respect to the least experienced residents, the next step should include reworking and relaxing the work hour restrictions for more senior residents.

Augustus D. Mazzocca, MD: The PGY-1 rules that began in 2011 where the PGY-1 did not have “direct supervision” and work shifts did not exceed 16 hours have not changed their clinical abilities in my opinion. The changes that have been made in regard to tailoring interns’ rotations is a step forward. It gives us a greater ability to identify specific areas of weakness within the intern year or areas that should have more attention within individual programs and address them by increasing exposure to different clinical entities. For example, we have identified that the suturing ability of residents has declined so we have increased their plastic surgery experience. In addition, we have tailor-made programs for preoperative evaluations, including cardiology, endocrinology and pulmonary, so they can become facile in completing preoperative evaluations. We also schedule rotations in rheumatology, osteoporosis and neurosurgery to improve their understanding of the management of other non-orthopedic musculoskeletal conditions.

Paul Tornetta III, MD: The changes in the PGY-1 year have been to the residents’ detriment. There is no escaping the fact that experience and exposure to patients and their problems allow residents to solidify their reading and remember more. The idea that more time away from patient care will somehow create greater competence is flawed on every level. While these changes were certainly well-intentioned, they were made far removed from the day-to-day training of physicians. The required changes, namely that interns not be permitted independent decision making before their knowledge base is sufficient, are included in the changes, but underscored by a lack of confidence in their potential progress. The oversight required was long in place in most surgical training programs and not something new to any of us.

The hierarchy in the hospital-based systems did not allow for interns to act independently in acute or serious situations, nor in the evaluation of acute injury. This is appropriate and remains unchanged. In the past, the intern year was one in which new physicians, with a broad-based overall understanding of physiology and anatomy apprenticed in the practical application of their future art. They felt the need to learn in order to provide for their patients, and they felt an obligation to them that is now, sadly being forced out in favor of a shiftwork mentality that is likely the greatest threat to quality health care.

Our current interns are the same as they have always been — interested, enthusiastic and excited to be involved in and learn their craft. Only now, instead of enthusiastically welcoming them to the team and allowing them to feel the true responsibility of their patients’ well-being, we require them to leave and pass on patient care to the next person in line. Despite formal sign-out requirements, this results in drops and failures more often than a lack of knowledge ever did.

Our interns are no longer learning to be physicians first and orthopedic surgeons thereafter. They are being taught and forced to become triage personnel and call consults rather than treating problems. I want to be clear that this is not the fault of the interns, but the changes in training that deem an orthopedic surgeon should be a technician and not a doctor. It takes experience seeing the normal to understand the abnormal. It takes multiple exposures to problems followed by reading and discussion to cement concepts and patterns. I fear we are restricting our interns’ abilities to develop the gestalt that more hours and exposure created, that feeling that more senior surgeons get when something is not right that often leads to heading off a problem before it is too serious or non-salvageable. Through no fault of their own, we are forcing the current interns to be less concerned, less experienced and less competent than their predecessors.

The goal of not allowing interns to make mistakes may be met, but this would happen with correct supervision — a solution that would not create more potential mistakes down the line. This change may make life easier for the interns, but it is a significant detractor from their maturation as physicians.

Levine: There has been a national increase in the percentage of residents applying for fellowships as well as a trend of residents pursuing two fellowships. Is this a reflection of the 80-hour work week? What is your comfort level with your residents’ proficiency as they graduate and start fellowships?

Black: These are separate but related issues. The trend toward increasing degrees of specialization in orthopedics has been going on for many years, precedes work hour restrictions, and is multifactorial. I do not think it is insignificant that most of their teaching is done by highly specialized orthopedic surgeons who are often reluctant to move out of their own specialty zone. I think graduating residents’ confidence with their skill sets, however, is a contributing factor to the decision to specialize, as well as market opportunities. I have never told residents they need to specialize due to limited competencies.

Braman: We are fortunate at the University of Minnesota to continue to graduate residents who are comfortable going in to practice without a fellowship. Our numbers are substantially below the 95% mark, and those graduates who leave our program and serve the people of Minnesota do a good job providing care in the community. At the same time, it has become harder to provide opportunities for the residents to learn all they need in the 5 years of residency.

Hiring ancillary providers is one way to get residents to the operating room (OR) more often. While this may help with the surgical skills, it robs the educational system of much of the work needed to learn how to be a surgeon in practice. Elimination of the “scut work” of surgical practice alone does not solve the problem. As any practicing orthopedic surgeon knows, plenty of forms and dictations go along with the daily grind. It is only by learning to balance this with the surgical aspects of our discipline that we can become effective orthopedic surgeons in practice. Furthermore, most of the emphasis on training during the past few years has been on surgical skill development. There continues to be a significant role for diagnosis and management. These skills need to be honed over time as well. More time in clinic, so residents can learn how to indicate and rehabilitate patients as well as to operate, is needed if we are to prevent residents from becoming technicians instead of physicians.

Egol: The residents we train are at an appropriate level compared with previous trainees at the time of graduation. The difference is when they reach that proficiency. In the past, it was common for a PGY-2 or PGY-3 to become facile in performing primary total hip and knee arthroplasty, ACL reconstruction and basic fracture work. Now our residents do not reach the same proficiency level until PGY-4 year because much of the previous operative experience was during post-call time in the junior years. Now, it is pushed back to times in our program when call is less prevalent.

The supervision of residents has improved significantly during the years, and this has helped improve the quality of training despite the diminished time available to train. I believe the spike in fellowship applications is a result of residents’ feeling they missed out on many clinical opportunities secondary to adherence of ACGME work hour policies. In addition, I think many residents feel they have to do a fellowship to make themselves more competitive in the job market. This is especially true for residents who wish to practice in large metropolitan centers where the job market tends to be more competitive and subspecialization is commonplace. I feel the trend toward the more popular fellowships is as much a desire by current trainees to avoid inpatients and call responsibilities that go along with general practice.

Mazzocca: It is my opinion, and that of our residents, that the increase in fellowships is driven more by the marketplace and job obtainment than a perception of unpreparedness or lack of competence. We believe that most, if not all, programs still do a good job. We are concerned about orthopedic training and provide residents with excellent clinical orthopedic training. The idea, that somehow they do not feel competent or proficient is inaccurate, from my perspective, and the reason for the increase in fellowship pursuit is due to job competitiveness and having a niche once they start their careers.

Tornetta: This trend is multifactorial. There are market and logistical pressures that affect residents’ decisions to do fellowships as well as their self-perceived competence. If one compares the amount of experience a current resident has against one trained prior to the 80-hour work week, it would take 7 years of the current residency to equal 5 years in the past. This equates to less experience and less confidence. Programs are mistakenly forced to worry primarily about case numbers, with a newly instituted list of minimums. With less time and the mandate to do a randomly generated number of certain types of cases, something must be lost. That something is everything out of the OR; the most significant of which is clinic work. Surgeons learn the most and mature their practices in the clinic. Learning when to operate, not how to operate, is the most challenging and important lesson in safe and effective practice. The current system does not apply enough value to this area of patient care. As a consequence, I believe current residents feel less able to make important decisions regarding patient care. This, as much as the desire to hone one’s operative skills, is a major factor in residents choosing to do a fellowship.

However, I do not believe this is the major factor. More than a lack of personal confidence in doing basic procedures, the culture of orthopedics has changed during the past 15 years. Practice environments no longer favor the “generalist,” and jobs are predicated upon subspecialty interest and training. Without a fellowship, graduating residents are at a substantial disadvantage to obtain employment. If they have personal reasons for wanting to be in a specific geographic area, then subspecialty training is a must. This trend was gradual for about 10 years, then magnified substantially during the past 5 years. A higher percentage of members of the American Academy of Orthopaedic Surgeons identify themselves as specialists or generalists with a subspecialty interest than in the past. This is the new normal. This development has stemmed not only from job pressure, but from the explosion of technology.

Our field has become more sophisticated, and in certain areas, it is not even reasonable to expect competence without a fellowship, such as oncology, pediatrics and spine. The desire that residents have to become masters of their craft also drives them to tighten the confines of their future practices. This is compounded by the fact that once surgeons limits their practice, they become quickly uncomfortable with anything outside their self-determined scope of practice. There should be a standard set of procedures and skills that all orthopedic surgeons have and this should be addressed in residency. The skills should include the ability to examine and diagnose problems, even if they are not standard within a surgeon’s practice area.

Training programs are universally staffed with subspecialists who are the role models for our trainees. Pressure from faculty to emulate their own practices and skills are indirect, but real. I think that many factors have created the current standard of fellowship training, most important of which is the need for subspecialty training in obtaining employment.

Levine: The Next Accreditation System (NAS) went into effect for orthopedic surgery on July 1. While it is too early to know its long-term impact, what is your overall perspective on this new system?

Black: The concepts behind NAS and the milestones are sound. Introduction of basic skills training in a simulation environment is important for both quality of care and efficiency. I think the milestones are a work in progress and are somewhat lacking in their ability to ultimately determine readiness for independent practice. They are a good start, however, and will serve as the necessary foundation going forward.

Braman: We have had a basic surgical skills program for several years in partnership with our general surgical colleagues. It consists of pre-testing with an Objective Structured Assessment of Technical Skills (OSATS), a structured curriculum that covers everything from aseptic technique and wound management to VAC placement and team sign outs. This is a combination of didactic and hands-on teaching, and a series of OSATS for assessment. There is an OSATS post-test as well. We have studied it and can demonstrate that our trainees improve after exposure to our curriculum.

We chose to continue this program as it has been effective and keeps us in compliance with the new regulations. We do this over several months at the beginning of the intern year one morning a week rather than in a 1-month block. It works well in our system as the general surgical rotations are used to having the interns absent for this period during those months. Working with the general surgery department also enhances collaboration and reduces the need for parallel and redundant curricula, thus reducing the need for faculty time in both departments.

To include more orthopedic skills in the curriculum, we will also be including a week of intern intensive training. This will include exposure to the required modules and will be part of the spring curriculum. Lastly, we will pilot our arthroscopic skills trainer this fall. We have developed a low-fidelity simulator that we included in our curriculum. It is designed to teach visualization, object manipulation and triangulation in a self-directed environment that does not require direct faculty involvement. We will plan a multicenter trial and will include it in our curriculum for residents after further validation.

The challenge is that we are in the process of engaging in “competency-based assessment,” yet there are no meaningful metrics for assessing competency. Swapping of time-delimited qualification for arbitrary and invalidated “competency” metrics is not an improvement. The call for change in our system has not been made because our current system is churning out poor technicians and impersonal or unqualified physicians. Rather, it is being made because the milestones will ensure that [graduates] demonstrate readiness for independent practice and possess the attributes that the public deems to be important in physicians.

If this is the case, then more gradual change would have been prudent. Shifting the entire system for assessment based on this decision puts our current successful system at risk. If we were to set the same expectations for educational changes we have for clinical changes, then we would answer this call for change with the usual skepticism and demand to see data justifying the change. Unfortunately, we are not allowed to demonstrate any such reserve with educational mandates handed down by the ACGME.

Egol: Having defined metrics to determine competency is a good idea. This is an improvement of the current practice of subjective evaluation that differs between evaluators and training sites. Problems can arise without consistency. These problems tend to become obvious when there is an underperforming resident, and a remediation plan needs to be developed. Lack of documentation to develop such a plan is always a problem for the program director. The way the new system is set-up is somewhat cumbersome, especially for larger programs. With all new programs, a learning curve will be in play and programs will adjust to the new requirements. Change is difficult, especially for those who feel they have a long track record of excellence in training methodology.

The basic skills requirement can be approached in a number of ways and is, in general, an excellent idea. As orthopedic surgeons, we have been engaged in simulated skills training for more than 40 years. Residents and staff have attended AO courses and other skills courses as part of their training and this is probably one reason why trauma is consistently an area where trainees are given the most autonomy.

At our institution, we began with a focused month of skills for interns. The program consisted of a combination of clinical and simulation training. The 5-day a week curriculum was structured so various clinical skills were taught by different members of the faculty and the medical center. The trainees were evaluated with checklists and videotaped for review. The program focused on communication skills, professionalism and technical aspects of fracture repair, arthroplasty, arthroscopy and hand surgery. We believe this program has given our new trainees a leg up compared to previous classes.

Mazzocca: The 16 milestones requirements will change the way we evaluate and the way residents self-evaluate. We have made many steps to make this a positive process. We have had a successful bioskills training program for 11 years. Now, our residents have 24-hour access to a simulator that contains both the shoulder and knee. Residents are able to come in any time to practice knot-tying and basic arthroscopic skills. We have basic surgical skills one to two times a month for residents that not only involve arthroscopy, but also involve open procedures, such as cervical and lumbar spine procedures, total hip arthroplasty, total knee arthroplasty, basic hand and elbow procedures, open shoulder and knee procedures, as well as foot and ankle procedures.

Tornetta: The NAS is a major overhaul of the method of accreditation. This is primarily in the area of paperwork and not anywhere else. While the idea of surgical skills training and simulation is wonderful, it is not new. Most programs, if not all, have had “bioskills” sessions, have had cadaveric dissection sessions, have taught casting and immobilization techniques, and have trained residents at all levels with these methods. Selecting specific skills to train as a core makes sense and will encourage programs to meet basics, but the side effect may be a loss of other, possibly more important events as the hours a resident can be in the hospital are limited. If a day is devoted to suturing and knot tying, which most residents do on their own during own time, then maybe a more sophisticated experience is lost. Overall, the concept of skills training is valid and helpful in giving residents the tools needed to begin their operative careers and I am in favor of it.

However, the dogmatic way in which it must be carried out is not helpful. In all aspects of the new system, paperwork is increased. In my opinion, like any other obligatory paperwork, the boxes will be checked, but it will mean little in reality. The onus to become proficient is, and has always been, on the individual. While programs can provide the initial steps in training, the individual resident must find time to practice skills outside of the work day. Competence putting a lag screw in a sawbones does not translate to success in the OR although we hope it jump starts the process.

The milestones project attempts to define competency-based training but without a real curriculum. Neither the American Board of Orthopaedic Surgery nor the RRC has accepted multiple attempts by outside groups to develop an orthopedic curriculum, which would be helpful for programs as well as residents. The new evaluations are required every 6 months, regardless of whether a resident has had additional experience in an area. The current evaluations of residents are meant to be supplanted with the new ones. Unfortunately, the new evaluations are check boxes with little room for descriptive analysis. The amount of work needed to complete these is disproportional to their value. Residents’ operative skills are rarely in one area. All techniques learned support all others. The burden of filling out and assessing residents in so many areas often is substantial and is likely to come from time spent teaching, mentoring and from other activities. The possibility of recognizing an at-risk resident has been brought up as a potential plus for this type of rigid system. But in reality, at-risk residents have been identified early. It is the remediation that is difficult, not the identification. In addition, all programs know all residents will need to achieve competence or the program will be looked at poorly, again favoring a “we must check the boxes” attitude.

Time will tell if this system adds anything to the evaluation process or if it is another step in the creation of empty documentation. I am sure I sound skeptical of these changes and I mean to. Like every decision we make in medicine, we need to look at the natural history. Only once a potential problem is identified do we consider intervening, and even then we only intervene if we have a high level of confidence that can we treat the problem to avoid potential dysfunction.

Using this methodology, I am at a loss to identify what problem NAS treats. My opinion of past years of residents is that they were competent to go into practice when leaving our programs. I do not believe increasing the required paperwork and forcing specific changes in the resident evaluations will make them “more competent” or have any appreciable change.

Levine: An increasing percentage of orthopedic surgery is performed in outpatient settings, yet residents spend most of their training time in a more traditional hospital-based paradigm. Given the changes noted above, are residents spending their 4 years in orthopedic surgical training in the best environment to prepare them for their future careers?

Black: I do not agree with this assumption. Our residency curriculum encompasses the broad spectrum of orthopedics. I realize this varies among programs, but we have our residents spend a day per week in clinic, regardless of service, and where they operate depends upon their specific rotation. On the sports medicine rotation, most of the time is in the office or outpatient surgery center. On the trauma service, with the exception of office hours, they are in the main OR. When on the shoulder and elbow service, time allocation is somewhere in between working in a variety of settings, including the community hospital, is a good learning experience.

Braman: I do not believe residency education needs to mirror the practices most surgeons have after graduation. Certain areas are critical for residents to experience, even if they do not choose to do them in practice. The same is true of practice locations and types. Inpatient and outpatient environments expose residents to different things. There is a need for trainees to learn how to work in interdisciplinary teams, and manage medically complex and orthopedically complex patients. Consequently, our program emphasizes in-hospital training early in the cycle. Furthermore, trauma is a great crucible for learning orthopedic principles and skills. Therefore, trauma is emphasized early in the system. As residents become more comfortable with the management of complexity and working in teams, it is appropriate for them to concentrate on isolated orthopedic pathologies and learn the practice of outpatient orthopedics. Consequently, our fourth and fifth years of training are heavily weighted to the outpatient setting, exposing residents to same-day surgery and ambulatory care.

It is beneficial to have residents exposed not only to inpatient and outpatient experiences, but also a variety of different practice types. In our program, the residents will see a private practice outpatient model, two level-1 trauma centers, a VA hospital and a large hospital-owned group of surgeon employees and the traditional university-based academic practice. This allows residents to understand what life might be like if they are in a physician-run multispecialty practice vs. a hospital-employee setting. This is of increasing importance with the movement of graduates into the hospital-employee practices. The need for such varied exposures is one more reason why compression of the working experiences with duty-hour limits challenges our ability to train residents in 5 years.

Egol: Most surgeries at our large urban, academic medical center are performed in the hospital. The hospital paradigm remains the best setting for training because it provides central access for all trainees to facilities and resources. The purpose of surgery centers is to make money for physicians vested in the venture and there is nothing wrong with that. Our academic medical center has an ambulatory center as part of its physical plant. The key is not where the surgery is done, but who is supervising the residents and to what extent their work is being monitored by faculty responsible for their education.

Certainly, the clinical competency committee and or program director must vet any offsite educational experiences to determine the value of the experience. Physicians supervising the trainees must have clear instructions on the goals and objectives of the rotation they are supervising. Surgery centers will likely play an expanding role in the training of future residents and fellows, but will not replace the hospital-based program. If a sufficient volume of orthopedic cases occurs at the surgicenter site, the program has a responsibility to determine whether there are adequate resources and oversight for trainees to participate at these sites. My main worry having trainees at these sites is the possible lack of structure. Program directors must ensure there is not a greater service over education philosophy at these sites.

Mazzocca: Our residents spend roughly 60% to 70% of their time in outpatient procedures and 30% to 40% of their time on inpatient procedures. At this time, arthroplasty, spine and trauma are the basis of our inpatient experience. Foot and ankle, shoulder and elbow, hand and wrist, and general sports medicine are mostly outpatient, so most of our resident rotations from PGY-1 to PGY-5 involve both the inpatient and outpatient setting. This distribution is probably residency-specific, but with the addition of physician extenders, covering of the inpatient cases is not as critical. Our residents participate in cases for educational needs only and not for service. We review our schedule and how well we are educating our residents on a monthly basis with small adjustments to their schedule happening in real time. This constant oversight is important as our residents rotate at community-based hospitals, free-standing children’s hospital as well as at the university hospital. The best environment is going to be different for each resident, so it is our job to maximize the resident’s educational experience.

Tornetta: The most important question is whether trainees are given ample exposure to the clinic setting, rather than the OR, be it an inpatient or surgicenter. The most important skills a surgeon must learn are learned there. These include how to interact with patients and families, shared decision-making, proper and complete consenting, follow-up and professionalism.

In our program, we still ascribe in many ways to an apprenticeship model with residents assigned to a service for months at a time, including the clinic and OR with limited staff, to understand the full spectrum of each practice area. Unfortunately, the minimums of cases needed may push programs to break these important bonds in favor of a few cases of one kind or another. Pulling residents from a fracture clinic to make sure they are present for one more closed reduction percutaneous pinning of a supracondylar distal humerus will only hurt their experiences. Likewise, having to pull them from a rotation to get more of another rotation is not helpful.

By example, I am a trauma surgeon and have my chief residents with me for a fifth of the year. They do not, in that time, do the requisite number of tibial nails, but I would bet they do them correctly with excellent techniques when they leave my service. Is it better to have the skills to perform the surgery or to do the requisite number? I prefer they are able to discuss the pros and cons of this operation with patients clearly, and see how patients do after both operative and nonoperative management in the clinic than do 10 more nails.

I would make a plea for losing the minimums, which in my estimation are relatively arbitrary, in favor of allowing the programs more freedom to allow for more time in the clinics and outpatient settings.