When I was a second-year resident, an attending 30 years my senior told me that he used to re-read his surgical textbook from residency before every operation. Impressed by his dedication, I tried this practice myself, but the habit didn’t stick—not that it mattered. Orthopaedic surgery is changing so rapidly that thumbing through books from my residency days is unlikely to be helpful, anyway.
How do private-practicing orthopaedic surgeons grow their knowledge base when most of the day is spent handling the overwhelming pressures of running a practice? There is certainly no lack of external sources delivering their content our way, and there are a number of high-quality journals and other kinds of educational resources available, as well, like the Journal of the American Academy of Orthopaedic Surgeons and AAOS Now.
Beyond better access to information, the nature of post-graduate education has evolved, and in my view, the value and relevance of continuing medical education (CME) is far better today than it was even a decade ago. I believe there have been at least three major improvements in how CME is delivered to orthopaedic surgeons, and these innovative methods have dramatically improved how private-practicing orthopaedic surgeons maintain their knowledge base.
Web-based Longitudinal Assessment
While some may not be thrilled with American Board of Orthopaedic Surgery’s (ABOS) recertification exam , ABOS Diplomates generally have embraced new CME testing options like the Web-based Longitudinal Assessment (WLA). This method of recertification is based on demonstrating the knowledge attained through reviewing high-quality resources in orthopaedic surgery. Each year, the ABOS engages with the American Academy of Orthopaedic Surgeons (AAOS) and the specialty societies to develop a list of more than 100 resources from which the Diplomate chooses 15. The content is driven by thought-leaders both within and outside of orthopaedic surgery. The Diplomate in this pathway commits to reading 15 articles and taking a 30-question online open-book examination each year to demonstrate ongoing mastery of current concepts in the specialty, as outlined by those chosen resources; the passing score is 24 of 30 correct answers.
By enrolling in WLA, each user knows that he or she will be held accountable for keeping up with the most-important aspects of orthopaedic surgery, which should be enough motivation to read the materials chosen by the user for deep comprehension and practice improvement.
Some orthopaedic surgeons find in-person CME offerings more relevant to what or who the treat on a daily basis compared to written or online offerings. I co-chair two separate trauma courses every year, and the format of these offerings mirrors much of the rest of courses nationwide. We specifically instruct our speakers to deliver three to five practical tips that the private-practicing orthopaedic surgeon could put to immediate use at their practice. No longer do we drone on and on about the origins of fracture classifications or the evolution of an intramedullary nail. Instead, we use real-world examples from our own practices, and apply specific learning objectives to help the attendee get the most from the experience. I believe that lectures delivered in this format are the most memorable, and feedback from those who have taken courses formatted this way suggests this is true. As typical with most trends in adult learning, our courses feature hands-on elements, where participants handle implants and practice techniques. Discussion forums, debates that engage the audience, and difficult-case sessions often engage learners and can potentially improve retention of the material.
Journals Embracing Change
Orthopaedic journals like CORR® and the Journal of the American Academy of Orthopaedic Surgeons are embracing the new reading habits of their audience. Short commentaries like CORR Insights® are designed in an easy-to-digest, three-question format for the busy clinician. By answering the questions (where we are now? where we need to go? how do we get there?) commentators give readers a new perspective on a recently published study.
CORR also has added columns that engage readers, including Clinical Faceoff [5, 6], which presents a debate on a contemporary clinical challenge between two subject-matter experts whose views diverge on how to manage the problem in question. Recent Faceoffs have covered whether arthroscopic meniscectomy should or should not be performed in patients with early arthritis , and whether acromioplasty should be part of our management of patients with rotator cuff disease . In their Editors Spotlight/Take 5 feature, one of CORR’s editors provides a short commentary on the article from each issue of the journal that has the broadest general-interest appeal, and the commentary is followed by a five-question interview in which the author of the article takes readers behind the discovery . Along similar lines, AAOS Now (by mail and online) and AAOS Headline News Now (online only) provide quick bites on timely orthopaedic topics.
Other resources include the Clinical Practice Guidelines, Systematic Reviews, and Appropriate Use Criteria developed by the AAOS and the specialty societies. These evidence-based recommendations are compiled from a strict compilation of high-quality literature distilling the essential evidence from the mass of available studies. There are many of these available including “Management of Surgical Site Infections” (http://www.orthoguidelines.org/topic?id=1022) and “Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty” (http://www.orthoguidelines.org/topic?id=1006) to name two. These specific resources can be found on the AAOS website or downloaded as a smartphone applicationhttp://www.orthoguidelines.org/ . Providing this information quickly through different digital platforms and even through social media has increased the availability of this knowledge. Orthopaedic surgeons should be keenly aware of the recommendations and consensus statements from these works.
The future is exciting in that the explosion of access to knowledge seems to be continually increasing. While I am pleased that the CME courses I’ve helped lead have become increasingly oriented around case presentations that deliver memorable take-home messages (“Here are five things you need to know about medial tibial plateau fractures”), I believe most CME courses still need to better prioritize the needs of contemporary surgeons. Surgical simulation is dramatically increasing in popularity, and courses that help surgeons with the technical aspects of surgery will be far more beneficial to our profession. The open format of presenting cases and discussing specific scenarios are highly productive in terms of learning, but the instructors must ensure that these do not become subjective “expert opinion” diatribes. These interactions must be based on high-quality evidence. Additionally, instructors must become more open to abandoning their lecture-heavy teaching approaches for more-effective and collaborative adult learning methods. Podcasts and video offerings on journal websites are becoming more prominent and I expect that interactivity between journals and their users (and users and their instructors) will become more common in the years to come. Finally, our profession must take full advantage of the massive work done by the AAOS to develop clinical practice guidelines and appropriate use criteria, as their recommendations based on peer-reviewed high-quality manuscripts are often the best distillation on a topic that is available.
1. American Academy of Orthopaedic Surgeons. AAOS Strategic Plan: 2019-2023. Available at: https://www.aaos.org/strategicplan/
. Accessed July 15, 2019.
2. American Board of Orthopaedic Surgery. The Diplomate eNewsletter Spring 2019. Available at: https://www.abos.org/news/the-diplomate-newsletter/the-diplomate-enewsletter-spring-2019.aspx#president
. Accessed July 15, 2019.
3. Bernstein J. Not the last word: The time to fix abos recertification has arrived. Clin Orthop Relat Res. 2018;476:1928-1930.
4. Leopold SS. Editor's Spotlight/Take 5: Eligibility criteria for lower-extremity joint replacement may worsen racial and socioeconomic disparities. Clin Orthop Relat Res. 2018;476:2297-2300.
5. Levy BA, Sihvonen R, Marx RG. Clinical Faceoff: The role of arthroscopic partial meniscectomy in the treatment of meniscal tears. Clin Orthop Relat Res. 2018;476:1393-1395.
6. McFarland EG, Matsen FA 3rd, Sanchez-Sotelo J. Clinical Faceoff: What is the role of acromioplasty in the treatment of rotator cuff disease? Clin Orthop Relat Res. 2018;476:1707-1712.