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Surgical skill education: Deficiency in the learning curve has to change
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The education of orthopedic surgeons continues to evolve with most of the focus on the acquisition of knowledge and becoming proficient in the treatment of many complex musculoskeletal problems. Residents and fellows learn from faculty in a variety of settings and digital resources. Then after residency, orthopedic surgeons take their steps toward certification through examinations by the American Board of Orthopaedic Surgery.
However, the process to assess technical surgical skills is almost nonexistent and is certainly antiquated. The master-apprentice model of teaching surgical skills is inadequate to effectively train today’s residents, fellows and practicing orthopedic surgeons. The model may have been effective decades ago when surgical skills focused on basic principles with limited technological options. However, today’s orthopedic surgeons not only have to be capable of complex surgical skills, but they also have to be competent with rapidly progressing technology that requires an advancement of skills beyond a fixed point in time, such as residency education.
Further challenging the surgical skills education for residents and fellows is the required 80-hour work week. Technical skills require extensive repetition to achieve mastery. In most programs, the time dedicated to surgical skills is inadequate to produce mastery of the many skills required to practice general orthopedic care. Furthermore, the concerns for the best possible patient care and the litigious medical environment has discouraged many faculty to allow surgeons in-training to learn and practice their surgical skills on patients.
Anthony A. Romeo
New surgical approaches, techniques
With new technology and innovation comes new surgical approaches and techniques. Orthopedic surgeons must continue to learn and practice new surgical skills, as not all are not easily transferrable from other areas of orthopedic surgery.
The traditional methods used to acquire technical skill and achieve mastery include observation of surgery, assisting the surgeon performing the surgery, direct guidance for the technical steps by the master surgeon and then independent performance of the procedure. Expertise is often recognized when the surgeon is then able to demonstrate and teach the procedure to other surgeons. Although the simplified concept of “see one, do one, teach one” is fictional — as numerous studies have shown a typical learning curve for learning a new procedure is 30 to 50 cases — a challenge to our educational system remains. The surgical skill education of residents and practicing orthopedic surgeons is not well designed to provide a method of learning and mastering technical skills other than practicing on patients.
Fundamental and well-understood disease processes and surgical principles are often challenged by newer and more technical surgical approaches and techniques. Oftentimes, the newer techniques are accompanied by new devices and implants and their adoption is encouraged by the companies and surgeons who develop them. Surgeons may presume that since the underlying principles have not changed, there is little learning curve to incorporating the new device or technique into treatment. However, there are numerous examples, such as humeral head resurfacing vs. standard anatomic hemiarthroplasty and newer rotating platform knee arthroplasty vs. older cruciate-retaining knee arthroplasty, where new techniques may have higher complication rates and lower patient satisfactions scores.
Surgery is not a ‘spectator sport‘
The current model for developing technical skills in the OR is archaic and must be improved beginning with residency and continuing to every level of an orthopedic surgeon’s career. There is no effective method to provide residents with similar experiences in the types and quantity of cases so they meet the learning curve and see variability in musculoskeletal conditions. This may be one reason that more than 90% are opting for an additional fellowship year of training.
Surgery is not a “spectator sport.” It cannot be adequately learned by consuming digital information and watching others operate. Residents and fellows must have an environment to practice with their hands, using their hand-eye coordination and the nurturing supervision of faculty.
The practicing orthopedic surgeon needs to have a similar process of acquiring additional or unique technical skills. With clear evidence that 30 or more cases is needed to work through a learning curve, other opportunities besides practicing on patients need to be considered. A weekend cadaver lab course is one of those methods, such as is offered at the Orthopaedic Learning Center in Rosemont, Ill. Numerous orthopedic device companies provide technique-based educational opportunities as well.
Hands-on experiences
As we convene at the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting, we should look for opportunities for hands-on, technique-based surgical education. Educational opportunities that offer hands-on experiences are invaluable as we work to improve surgical skills. Although much improvement has been made during the past decade, the role of simulation for practicing technical skills remains in its infancy for orthopedic surgeons. Other surgical specialties, just as high-risk professions like aviation, have embraced the value of simulation for education and the evaluation of the technical competency of trainees. This process will be part of orthopedic surgery training and certification in the future.
Simulation can be a vital part of hands-on orthopedic training. We see evidence of its value in all aspects of our lives. A wide variety of simulation tools are available, from a simple “box” that helps to improve hand-eye coordination to virtual reality-based devices that focus on arthroscopically based procedures. Advancements in virtual reality in the computer gaming industry will lead to improved simulation for surgical training.
We may attend future AAOS Annual Meeting and there will be essentially a massive “arcade” room where we practice routine procedures, learn new procedures and develop techniques. The future learning curve will be significantly accomplished outside of the OR, thus improving the quality, consistency and safety of surgical care.
- References:
- Lebon J, et al. Orthop Traumatol Surg Res. 2014;doi:10.1016/j.otsr.2014.05.012.
- Nunley RM, et al. Clin Orthop Relat Res. 2015;doi:10.1007/s11999-014-3713-8.
- Raiss P, et al. Int Orthop. 2015; doi:10.1007/s00264-014-2540-6.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosures: Romeo reports he 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.