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What Gives? Orthopedic Residency Education

Orthopedics This Week—June 10, 2010

More to learn, less time to learn it, and a field that is not always exactly in agreement about what should be learned…these are some of the issues facing hospital administrators, educators and others standing on the shifting sands of U.S. residency education. Now, thanks to a few visionaries in New York, they have found firmer footing.

Laura Robbins, DSW, a researcher at Hospital for Special Surgery is lead author on an article recently published in the Journal of Bone and Joint Surgery that outlines the results of an orthopedic residency directors peer forum. She says, "In 2006-2007 we at HSS began to seriously look at the issue of how to maintain our world class orthopedic residency training program and still meet the stringent external requirements such as the work hour restriction mandated by the Accreditation Council for Graduate Medical Education (ACGME). The issue arose in a number of meetings and we all came away feeling like we were the only program experiencing these difficulties. A 'eureka' moment struck, and we decided to convene a meeting of program directors from several other top level training programs in order to determine what issues our colleagues were facing. I think everyone was a bit relieved to learn that we are all dealing with the same challenges."

As the two-day meeting progressed, certain themes took shape. "Nearly everyone has felt the crunch of the 80-hour work hour restrictions mandated in 2002," says Dr. Robbins. "You will find much in the literature about how learning basic orthopedic surgery skills may be compromised because of things such as less time in the OR, reduced continuity of care, and less experience with disease process evolution. In our discussions we reviewed the possibility that these issues may also be affected by other ACGME restrictions, such as the eight-hour break between shifts and mandated 'one day off in seven' days. To meet these challenges, most if not all programs have made changes to their call systems, hired more Physician Assistants and Nurse Practitioners, and restructured the scheduling of night floats."

Then the group turned its attention to an area prone to turf battles...what exactly is the most important knowledge that orthopedic residents need to learn? Dr. Robbins says, "Program administrators must look at what it means for residents to be competent in the exam room and in the OR. While this is a broad topic, the group did identify the first step, which is to define what core orthopedic knowledge should be imparted to residents during their training. To do that, the group suggested that administrators examine such issues as how many cases of any given type a trainee should perform, how much exposure to X,Y and Z a resident should have outside of the OR, etc. The ACGME does not prescribe how much residents need to know for any given surgery, and while required to ensure preop or postop time engaged in these activities, it is left to the individual program to figure out the right formula for effective resident learning."

New forms, new labs, new focus…these are some of the core knowledge recommendations flowing from the HSS meeting.

The third theme emerging from the meeting of orthopedic minds captured a trend in the field…measuring. "Outcomes research is the current trend, and for good reason. The group recommended that program directors and administrative oversight groups should define and require standard formats for measuring residents’ performance (such as resident portfolios). Tools such as the portfolio would allow useful performance outcomes such as resident self learning case vignettes that can then be used with more objective performance data such as OITE [Orthopaedics In-Training Examination] scores by teaching faculty and program directors to improve the overall resident curriculum. Among the other proposals was that there should be a standard format for the biannual evaluation process. The program directors selected the Duke University School of Medicine's format as a model. That format employs a resident-completed pre-evaluation form and an evaluation that includes input from mentor physicians, attending physicians, nurses, patients, other residents, and medical students. Lastly, it involves a face-to-face debriefing session between the resident and the faculty mentor to provide useful feedback and areas of mutual agreement for further training and development."

Also included in the benchmarking proposals was a recommendation that residents be provided with more meaningful feedback about their performance.


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