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We need to adapt orthopedic residency training
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The goal of an orthopedic residency program is to prepare a resident for life-long orthopedic practice. This includes competency in the evaluation and diagnosis of musculoskeletal disorders, establishment of appropriate nonoperative treatment plans, and when necessary, provision of technically competent surgical procedures. Additional goals are to provide a structured approach in the acquisition and maintenance of knowledge of orthopedics to allow for safe and competent care of patients.
In many programs, the learning experience can be substantially enhanced with the addition of mentorship in clinical and basic science research. While these principles are acceptable to many, the accomplishment of these goals, as well as defining the core set of knowledge that makes a surgeon competent, are subjects of significant debate among residency educators. A number of important factors need to be considered, including the reduced amount of time now available for residency education.
Work restrictions
Anthony A. Romeo
Anthony A. Romeo
Nearly everyone has felt the “crunch” of the 80-hour work restriction that was instituted in 2003 across medical discipline. It is interesting because there is no clear evidence that the mandate has improved residents’ training or well-being, or that it improved patient safety. Some people have argued that the “work-shift” mentality has, in fact, adversely affected patient care, encouraged residents to pass off the patient when the continuity of care would be better both for the patient and resident, and reduced the amount of time available to practice technical skills. Reduced work hours have led to many institutions hiring non-physician support staff. This is a positive trend because it reduces the service-only aspect of the hospital-based residency programs.
A key question without consensus is a basis of knowledge that comprises the ideal orthopedic surgery residency. One method is to look at highly regarded, traditional training programs and their core curricula. However, life as an orthopedic surgeon after training has significantly changed. As such, we need to adapt and change to develop our residents into competent practicing orthopedic surgeons.
I believe many of today’s orthopedic programs, including some prestigious institutions, are in danger of providing inadequate education and mentorship to the future members of the American Academy of Orthopaedic Surgeons (AAOS). If we analyze the amount of time in the 80-hour work weeks that residents spend in the hospital taking care of medically ill patients and performing inpatient surgeries, such as complex reconstructions, then we would assume life after residency includes these responsibilities on a regular basis. However, for most orthopedic surgeons, it does not.
According to AAOS census data in Orthopaedic Practice in the U.S. 2012, 71% of the more than 27,000 practicing orthopedic surgeons are in private practice. Eighteen percent are in an academic center or hospital-based practice. For most practicing orthopedic surgeons, they spend 50% of their time in the office evaluating and treating patients with nonsurgical musculoskeletal problems. They spend the other 50% of their time in the operating room. It is likely that more than 80% of an orthopedic surgeon’s cases may be performed on an outpatient basis during the next 5 years.
This means that 90% of time is outside of any hospital setting for more than 20,000 practicing orthopedic surgeons. The percentage of surgical cases performed in an ambulatory surgical care center (ASC) will increase with the continued efforts to reduce costs and complications. During the next 3 years to 5 years, it is likely that 80% of the total number of orthopedic procedures will be performed in an ASC.
In the United States, hospital-based education programs focus on the highest complexity of care, rather than what happens for most orthopedic residents upon completion of residency programs. Currently, almost 50% of all orthopedic surgery residents apply to fellowships almost entirely based on outpatient surgery, such as sports medicine, arthroscopy, hand and upper extremity, shoulder and elbow. I believe it is time to focus on the core practice of orthopedic surgery, and then allow residents who want higher and more unusual complex skills to take fellowships in these areas.
Conflict of interest
The reasons proposed for the inability to make significant changes in the practice setting and service rotations are varied. Some physicians believe any significant change will reduce the competency of graduating residents. Other physicians believe residents cannot adequately be mentored and educated in a non-academic setting. Some physicians believe the delivery of care in an ASC is inferior to that performed in an academic hospital setting.
Whatever one’s reasoning, myths are often promoted by surgeons who have a rarely discussed hidden bias. Residents are inexpensive ancillary health care providers who are paid for by Medicare, which has remained unchanged since the Congressional Balanced Budget Act took effect in 1997. They provide the workforce for academic departments and are financed by an outside source while their efforts create revenue for departments and institutions.
As patients assume a greater level of decision-making with their health expenditures due to the Affordable Care Act provisions and the increasing number of high-deductible plans, more patients may chose procedures performed in an ASC whenever possible. On the near horizon, if not already in place, outpatient total joint replacement and most elective spine procedures may be routinely done in an ASC environment. This further reduces the case volume in a traditional hospital environment. Most residency programs will not have effectively adjusted to these changes if they try to perpetuate the past.
Many institutions argue they have lowered residents’ service components. However, when resident involvement was reduced by the government mandate of an 80-hour work week, they were supplemented or replaced by physician extenders. Hospitalists do the work previously done before by residents, but often at twice the salary of a junior resident. President Obama has promised a more careful look at the funding behind graduate medical education with an early suggestion that he will work toward a 10% to 20% reduction in payments. However, the “turf war” over resident work is likely to further discourage academic hospital-based programs from moving resident education into an outpatient setting.
Future direction
We have to educate residents on the business of medical care and orthopedics. As health care reform continues to reduce the reimbursement for services, business leaders will make decisions that are in their own best interests first. If orthopedic surgeons do not participate in the process, then we are destined to accept their decisions on our behalf. These decisions are made by professionals who have a significantly different set of priorities and a variable level of moral standards that does not include the experience of caring for patients.
We should be providing resident education that includes a variety of medical business issues, such as office practice management, cost-effective decision-making, personnel management, coding and billing, documentation, outcomes analysis, understanding government guidelines and mandates, understanding worker’s compensation and legal patients, as well as the management of outpatient surgical practices. Practicing orthopedic surgeons need to understand these issues on a daily basis to not only grow their practices but also increase their ability to care for patients effectively and more economically than a hospital-based system.
We also need to develop a competency-based evaluation of resident education programs. This requires education leaders to develop a core set of educational goals and standards, including technical skills. These technical skills will be used 80% or more of the time in an outpatient ASC setting and should reflect the current practices of orthopedic surgery.
We are our patients’ best advocates. We need to provide and manage the full service line of musculoskeletal care, which requires physician education and leadership in the practice and business of delivering state-of-the-art orthopedic care. No one is better suited to develop these skills than well-trained orthopedic surgeons who are interested in the continued improvement of patient care. In turn, orthopedic residency training programs need to better reflect this new vision and curriculum.
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Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.