The Association of Bone and Joint Surgeons sponsors an annual workshop named in honor of the former CORR Editor-in-Chief, Carl T. Brighton, who established the workshops. The intent is to discuss and analyze timely issues in the field of orthopaedics. For 2005, we explored a range of topics related to Orthopaedic Education. The American Orthopaedic Association joined with the Association of Bone and Joint Surgeons in sponsoring the workshop. The landscape of graduate medical education is undergoing great change and, while the popularity of orthopaedics has survived federal and institutional mandates of the 1990s for primary care physicians, no group is exempt from the current advent of resident work hour guidelines. Indeed, one might argue the entire spectrum of surgical specialties is particularly challenged by this new approach to limitation of resident duty hours. Moreover, rising health care costs and managed care contracts threaten the economic foundations of academic medical practice and, therefore, graduate medical education, and have far reaching implications for a host of issues surrounding medical research, education, and professionalism. Coupled with the arrival of the generation of baby boomers to the seventh decade of life, and the entry of generation Xs and Millenials into the medical provider pipeline, the rate of change in our system of graduate medical education has accelerated from evolution to revolution as we enter the 21st century. Accordingly, the topic of medical education is timely for the entire orthopaedic community, particularly for those involved in the preparation and teaching of the next generation of orthopaedic physicians.
In keeping with the tradition of these workshops as established by Dr. Carl Brighton, the format of presentation and discussion was structured to address the questions, “Where are we now?” “Where do we need to go?” and ′How do we get there?" Following an historical perspective on the evolution of the present day structure of orthopaedic residency education by Kettelkamp, the workshop addressed four themes in orthopaedic education. The format included three half-day sessions on Resident Selection, The Orthopaedic Clinician Scientist, and The Challenge of Continuing Competency and one full day devoted to discussion of The Optimal Residency Learning Environment. This publication is intended to collate the original presentations in a single volume, as well as chronicle the lively discussion that ensued among those experts participating in the workshop in November, 2005.
Selection of residents is hardly a new topic to orthopaedic educators. Evarts presented the findings of a task force on this subject commissioned by the former Association of Orthopaedic Chairmen in 1984. The applicant interview was felt to be an essential component of the evaluative process and personal involvement of the Chair was likewise deemed an important part of selection. Affective domain issues were recognized as the most common reason for dismissal and accounted for the majority of the one in six residents who were felt to be “errors in selection”. Dirschl reported on the University of North Carolina experience in an attempt to introduce some science into the process of residency selection. A quantitative academic score was devised to screen applications for interview; AOA status, USMLE board scores, publications, and clerkship grades in third and fourth year were found to be the most reliable predictors of later performance on ABOS part I and OITE examinations. Nevertheless, these metrics offered no advantage over non-quantitative selection methods in predicting eventual faculty evaluations of resident performance. Similarly, Hanssen presented a quantitative selection methodology developed at the Mayo Clinic. AOA election, junior year clerkship grades, and overall composite scores predicted performance by residents. While the part I USMLE board score correlated well with later OITE scores, as a sole indicator it was a poor predictor of resident performance. Mallott analyzed the Dean's letter and affective domain issues; a structured interview format, a critical reading of the Dean's letter in search of subtle tones, and attention to learning styles and depressive personality traits were suggested as helpful tools in resident selection. On a more scientific note, Hamstra discussed work with predicting technical competence and concluded that assessment tools were predictive of only initial performance on a mental rotation test and that technical tasks were imminently teachable. Furthermore, any differences in initial technical scores noted between staff surgeons, residents, and students disappeared after only 10 minutes of practice with the specific task. The challenge of resident selection remains more art than science and the use of specific quantitative data points only serve to narrow the prospective applicant pool rather than truly identify the “winners”. There is no substitute for careful attention to clues about affective domain issues and all assessment tools would appear to have little relevance to the ultimate technical proficiency of a surgeon.
The Orthopaedic Clinician Scientist
While nurturing the orthopaedic clinician scientist is, conceptually, a universally endorsed ideal, the practical implementation of such a strategy has been elusive. Brand underscored the dwindling numbers of successful orthopaedic clinician scientists, as measured by those attaining extramural funding for their work. Rosier emphasized the three Ts of success in overcoming institutional barriers for clinician scientists; Time, Team, and Tenacity were felt to be necessary components to the successful nurturing of young trainees aspiring to a combined career in clinical practice and research. Funding of one-half of salary for a half time presence in the research laboratory for a 3 to 5 year period was felt a reasonable startup commitment to an aspiring clinician scientist. Einhorn discussed extramural funding methods available to underwrite such an initiative and pertinent financial barriers to success, including the lack of peer appreciation of the non-economic contribution of the clinician scientist to the departmental mission. Anderson presented the Duke experience from the Department of Surgery with a required research term, emphasizing the role of new product development as a funding source for future educational and scientific initiatives in academic departments. Over the past three decades and 256 graduating Duke surgical residents, 136 (53%) initially accepted academic appointments, 70% of those remained in academic positions, and 2% (4 graduates) became independently funded NIH investigators. Segal presented the Penn State experience with an optional research year in the context of orthopaedic residency training and suggested an association between residents electing and completing an optional research year and those pursuing academic careers after residency. Bernstein presented the University of Pennsylvania experience with a required research year within the structure of orthopaedic residency training; among 127 residents who graduated from this program, 59% accepted faculty positions upon graduation and 17% eventually became members of the American Orthopaedic Association. It was concluded from the presentations and ensuing discussion that formal training in research during residency education fell far short of the exposure and support necessary to nurture successful career orthopaedic clinician scientists. Nevertheless, while not the pathway to producing more clinician scientists, a residency research experience was considered an important part of a curriculum designed to encourage development of critical thinking skills needed for the practice of orthopaedics.
The Optimal Residency Learning Environment
The learning environment for residency education is undergoing profound and rapid change, catalyzed by the advent of duty hour guidelines for postgraduate medical education. With this reality, we are well-advised to reassess our methods of teaching and learning during the period of residency education. Regehr discussed the concept of “purposeful practice” as it applies to residency education with the goal of improvement by making errors and advancing boundaries of knowledge through successive exploration and learning. In order to be “transfer appropriate,” he emphasized that methods of learning must match the anticipated methods of use. Hamstra reminded us that technical tasks can be taught and provided data suggesting achievement of “virtuoso” status required 10,000 hours of deliberate practice, but that gaining proficiency required much less practice time. Within the context of an increasing appreciation of the physiologic effects of sleep deprivation on the learning process, Lockley reviewed the science of sleep and the inevitable occurrence of attentional and reasoning deficits as they relate to both acute and chronic shortage of sleep. Considering the fact that a sleepless night on call seriously delays, or even prevents, the permanent imprinting of new knowledge acquired during the previous day, some practical modifications of our teaching schedules during residency would seem to be deserving of immediate implementation. The effects of sleep deprivation on performance deterioration have grave implications for patient safety and Friedlaender reviewed the impressions and results gleaned from an AAOS survey of orthopaedic residents. Ms. Jennifer Moody (Vice-President of American Medical Consulting) noted (in a presentation not included in this symposium) important differences between the generations. The task of graduate medical education and residency performance in the context of the expectations, ideals, and work ethic of the generation Xs and Millenials who currently populate our residency programs and differ dramatically from the baby boomer faculty from whom they are asked to learn. Such a philosophical disconnect between teachers and learners exposes a potentially substantial risk of dysfunction in our apprenticeship system of postgraduate medical education. Based upon an AOA survey of residents and program directors as reported by Peabody, work hour guidelines have resulted in negative attitudes towards residency education on the part of both residents and faculty alike. Such sentiment has contributed to burnout of both residents and faculty, as reported by Barrack, but faculty (the baby boomers) are generally happier and better adapted to these stressful work environments than their residents of younger generations. With diminishing contact time between residents and their faculty teachers and role models, the importance of specific efforts directed at teaching professionalism during residency has greatly increased. The ethos of professional behavior can no longer be left to adoption by natural course, but rather must be distinctly taught and modeled by our faculty, as discussed by DeRosa. Wilson outlined the inextricable relationship between teaching and learning, and therefore the benefit of teaching our residents to be teachers. Pellegrini highlighted the increasing importance of effective faculty mentors for our residents, particularly as they relate to the teaching of professionalism within the context of duty hour guidelines, and discussed some challenging aspects of mentoring that may be unique to the academic surgeon. On balance, the job of resident education has been challenged and made increasingly difficult by numerous external forces outside of the control of faculty teachers. Our response to these challenges will determine the future course, and effectiveness, of orthopaedic resident education. What is obvious from this discussion is that the quality of contact time between faculty and residents, compromised as it is in quantity by regulations on duty hours, assumes increasing importance in resident education. Our actions and behaviors, defined by Regehr and colleagues as the “hidden curriculum,” are deserving of increased scrutiny as the objects of our residents' mimicry and patterning of their own future professional behaviors. We cannot overemphasize the importance of this hidden curriculum in the development of our trainees.
The Challenge of Continuing Competency
The challenge of ensuring continued professional competency for the safety of the public under medical care has attracted increasing attention following the 2000 report of the Institute of Medicine. While safe and successful professional practice in many areas has long been suggested to be dependent upon the ability to “know what you don't know,” Regehr suggests that such an ability is not only uncommon but cannot be rationally expected to exist among most practitioners. Toward this end, Miller outlined the ABMS' current concept of “maintenance of competency” as a continuous process of professional skill maintenance rather than the previous sporadic approach encouraged by the process of periodic recertification. DeRosa outlined the experience of the ABOS with time limited certificates and the recertification process, Rosier explained the planned ABOS adoption and implementation of a continuous maintenance of competency approach, and Stern reported the role of a certificate of added qualifications in contributing to the life-long learning ethic based upon the experience of the Hand Surgery Certificates of Added Qualification (CAQ). Despite our idealistic desire that professional competency and life-long education are reliably self-imposed ideals of the medical community, it is both obvious and discouraging that legislated guidelines are necessary to best ensure the safety as well as trust of our future patients.
Vincent D. Pellegrini, Jr., MD
James L. Kernan Professor and Chair, Department of Orthopaedics University of Maryland Baltimore, Maryland