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The Evolving Structure of Orthopaedic Residency Education

Kettelkamp, Donald, B

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 16-19
doi: 10.1097/01.blo.0000224022.11282.71
SECTION I: SYMPOSIUM I: C. T. Brighton/ABJS Workshop on Orthopaedic Education
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Orthopaedic residency has undergone continual evolution since the early 1900s. Training has evolved from a preceptorship to a highly evolved and structured educational system which largely standardizes training throughout the United States. Approval and accreditation of training programs, as well as content, is now overseen by a hierarchical group of organizations with representations from a variety of medical societies and boards. The evolving process has served the public well, providing competent care of the musculoskeletal system.

The author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Correspondence to: Donald B. Kettelkamp, MD, 103 Windhover Drive, Chapel Hill, NC 27514. Phone: 919-968-0310; Fax: 919-942-8988; E-mail: dbcoket@aol.com.

As with other surgical disciplines, training occurred primarily through preceptorship until well into the 20th century. The initial formal structure began as a requirement for content of training as established by the American Board of Orthopaedic Surgery in 1944. These requirements, however, were intended as guidelines for taking the board examinations, rather than requirements for accreditation of training programs. Rather, formalization of educational requirements has been a continually evolving process.

I will review the history of that evolution, beginning with formalization of hospital requirements following the Flexner Report.1 The history illustrates not only the rich history, but the substantial changes in educational philosophy underpinning the changes.

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The Early Years

In 1914, the American Medical Association (AMA) published a list of hospitals approved for internships. In 1927, the Council of Medical Education and Hospitals of the AMA published a list of hospitals having programs in the various specialties that met with AMA approval.

During the early years of orthopaedic surgical education, the experience was primarily by preceptorship after the initial internship. This education plus practice and a thesis were necessary for election to the American Orthopaedic Association (AOA). In 1933, the AOA appointed a committee to consider graduate education in orthopaedic surgery. The American Board of Orthopaedic Surgery (ABOS) was the result and was incorporated on February 4, 1934.2 In the beginning, the AOA, the newly formed American Academy of Orthopaedic Surgeons (AAOS), and the AMA each appointed orthopaedic surgeons to the newly formed ABOS. The ABOS gave its first certification examination in 1935. This examination consisted of four essay questions regarding basic sciences and clinical orthopaedic surgery.

The ABOS recognized the necessity of improving the quality of orthopaedic education in selected hospitals by defining the minimum educational standards and by conducting examinations for those individuals who had completed the ABOS requirements. In 1937, the ABOS responded to a request from the AMA for recommendations and a list of hospitals suitable for residents in orthopaedic surgery. A residency training committee was added later. The ABOS secretary began investigating the hospitals that offered orthopaedic training and methods for review. The ABOS then learned that the AMA Council on Medical Education and Hospitals was conducting evaluations of hospitals that offered graduate training. This information was made available to the ABOS.

In 1943, the first revised rules and procedures of the ABOS spelled out the necessity for education in basic science, adult and children's orthopaedics, and fractures. In 1944, the basic science requirements were defined to include 40% pathology, 40% anatomy, 10% bacteriology, and 10% biochemistry-physiology. The specific content for each of these areas was further defined.

In June of 1944, the Surgical Specialty Boards considered a surgical year for all surgical specialties that would include the treatment of shock and hemorrhage, evaluation of surgical risk, pre and postoperative care, and fluid balance. The ABOS approved this content but did not approve a subsequent request to discontinue the ABOS Part I examination and substitute an examination on the content of the surgical year. The ABOS Part I examination began in 1943 after 1 year of accredited orthopaedic residency. The Part I examination consisted of written and oral tests covering anatomy, pathology, physiology, and biochemistry related to surgery and orthopaedics. The Part II examination was taken after completing residency and 2 years of practice. This examination consisted of written and oral tests covering operative techniques, fractures, other orthopaedic conditions, and basic science.

In 1948, approved residencies were available in orthopaedic surgery at 239 hospitals, and 718 residencies were offered. This was an increase from 200 positions in 1941. Also in 1948, the AMA and the American College of Surgeons (ACS) met to discuss the evaluation of training programs, including those in orthopaedic surgery. This led to confusion; therefore, after meetings among the AMA, ACS, and ABOS in 1949 and 1950, the following recommendations were made: (1) To encourage adoption by the sponsoring agencies of uniform standards for residency training in surgery; (2) to sponsor a single inspection service for hospitals offering such training; and (3) to approve and publish a list of acceptable residencies. Until 1959, the ACS wanted accreditation of all the surgical specialties under “one roof.” The ACS proposed a tripartite Residency Review Committee (RRC) consisting of the AMA, ABOS, and ACS to review all orthopaedic surgery residency programs. Fortunately, this did not come about because the ABOS would accept osteopathic physicians and the ACS would not. The ABOS did, however, require a year of surgical residency until 1958. At that time, the ABOS thought that the goals of the surgical year were not being met and that other specialties of medicine offered equal, although different, educations. The orthopaedic residency was changed to 4 years of orthopaedic surgery in 1991. As all program directors know, the requirements were changed in 2000 to specify the content of the postgraduate year 1 and put that year under the control of the orthopaedic program director.

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Oversight of Residency Training Programs by the Residency Review Committee

The RRC for Orthopaedic Surgery held its first meeting on Friday October 23, 1953. Dr. Hugh Smith was Chairman, and Dr. Mather Cleveland and Dr. Harold Sofield in place of Dr. Charles Frankle completed the representation from the ABOS. Drs. Guy Caldwell, Ralph Ghormley, and Edward Leverone were appointees from the AMA Council on Medical Education and Hospitals. At that meeting, they developed the workings of the RRC and approved and reviewed programs. In 1955, the RRC reinspected 118 residency programs and approved 13 new programs.

The RRC classified hospitals into three categories. Class I was a freestanding program accredited for training in adult and children's orthopaedics, and fractures. Class II programs were those that fulfilled the requirements for accreditation by the amalgamation of several hospitals. Class III programs were freestanding hospitals without the formal agreements to fulfill all the requirements for training. Plans were made to eliminate the Class III programs.

After World War II, a need existed for more orthopaedic surgeons. Many candidates had gained considerable experience and training in adult orthopaedics and fractures during the War but had no experience in children's orthopaedics. As a result, the ABOS offered a “limited” certificate from 1951 until 1958. Also until 1957, the ABOS accepted preceptorship training. This required 1 year of internship, 1 year of surgery, and 5 years of full-time assistantship to a board-certified orthopaedic surgeon and then 5 years of practice at an approved hospital. This training was found to be generally inferior to a formal residency program and hence was discontinued.

In 1972, the RRC became a tripartite committee with the addition of three appointees from the AAOS. It therefore became a nine-person committee with appointees from the ABOS, the Council on Medical Education of the AMA, and the AAOS. In addition to reviewing and accrediting orthopaedic residency programs, the RRC developed the special requirements for an educational program in the specialty.

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Oversight of the RRC by the Liaison Committee for Graduate Medical Education

Also in 1972, the Liaison Committee for Graduate Medical Education (LCGME) was formed to oversee the RRCs and the accreditation of residency programs. The LCGME had to approve the special requirements and any changes that the RRC requested. The LCGME became very unpopular with the RRCs. Part of the problem was that the LCGME tried to exercise too much control, often in areas in which the members of the LCGME did not have the necessary knowledge of the specialties. An example of this problem occurred in 1977 or 1978, when the RRC for Orthopaedic Surgery proposed changes in the special requirements. At that time, the Special Requirements for Residency Training in Orthopaedic Surgery had been unchanged from 1964 and were as follows:

“Surgical and orthopedic facilities must be satisfactory and clinical material sufficient to afford residents adequate experience in the correction of congenital and acquired deformities and in the treatment of fractures and other acute and chronic disorders that interfere with the proper function of the skeletal system and its associated structures. Residents should become thoroughly familiar with all methods of diagnosis and treatment, corrective exercises, physical medicine, operative procedures, and the use of orthopedic appliances. Instruction in surgical technique should be sufficient to enable residents to undertake operative work on their own responsibility, especially toward the end of the residency program. Clinical instruction should include teaching rounds and departmental conferences.

“Residencies must be organized in the fields of adult orthopedics, children's orthopedics, fractures, or in combinations of these. As preliminary training, the Council recommends 1 year of general surgery in addition to the internship.

“Quantitative Requirements-Both hospital and outpatient facilities are desirable, and institutions offering residency instruction should treat a minimum of 200 patients annually.

“Applied Basic Science Instruction-Anatomy, bacteriology, biochemistry, embryology, pathology, and physiology are especially desirable and should be closely correlated with clinical experience.”

The RRC for Orthopaedic Surgery repeatedly tried to upgrade these special requirements to improve the quality of education in orthopaedic surgery residencies and were repeatedly blocked by the LCGME. On one occasion, Dr. Robert Murray, Chairman of the RRC, and I as Vice Chairman spent the most frustrating day of my orthopaedic career trying to get the LCGME to approve the changes the RRC thought it needed. Fortunately, other RRCs also had difficulty with the LCGME. This ended in the discontinuance of the LCGME and the creation of the Accreditation Council for Graduate Medical Education (ACGME) in 1981.

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Replacement of the LCGME with the ACGME

The Accreditation Council for Graduate Medical Education is composed of five member organizations: The American Board of Medical Specialties, the American Hospital Association, the AMA, the Association of American Medical Colleges, and the Council of Medical Specialty Societies. Each member organization has four voting members. In addition, it includes three more voting members: a resident representative and two public representatives. Also, two nonvoting representatives are included: one from the federal government and the Chair of the RRC Council. The ACGME approves and publishes the “Essentials of Accredited Residencies.” The Essentials include the “Institutional Requirements” and the “Program Requirements.”

The Program Requirements are developed by the RRC and must be approved by the three parents of the RRC and after that by the ACGME. Typically, the ACGME delegates authority to the RRC to accredit the programs in their specialties. The Monitoring Committee of the ACGME reviews the minutes and procedures of the RRC but does not pass on specific decisions. The functioning of the ACGME is much different from that of the LCGME. The ACGME approved the Special Requirements for Orthopaedic Surgery that became effective July 1, 1981. This greatly strengthened the educational requirements for orthopaedic surgery residencies and enabled continued modification and improvement in the educational requirements for orthopaedic residency programs in subsequent years.

The Advisory Council for Orthopaedic Resident Education (ACORE) was formed in 1974 to serve in an advisory capacity for orthopaedic residency program directors. The members of ACORE were Drs. William Donaldson, Charles Herndon, Walter Hoyt, and Wood Lovell. The ABOS, the AAOS, the Association of Orthopaedic Chairmen, and the AOA were represented. ACORE had no official function in relation to program accreditation but did provide one or two orthopaedic surgeons who would visit a program and advise the program director regarding improvements he or she could make to the program. ACORE also compiled a list of “fellowships” available to orthopaedic surgeons after completion of residency. In 1980, this list included 150 programs. These programs were of varying quality.

The primary concern of the RRC regarding fellowships was that some fellowships did not offer a quality educational opportunity. The only way to improve this situation was the accreditation of the orthopaedic fellowships. In the early 1980s, the policy of the ACGME was to accredit only those programs that led to certification. In the case of hand surgery, the RRCs for Orthopaedic Surgery, General Surgery, and Plastic Surgery developed Special Requirements for Fellowships in Hand Surgery. The special requirements were approved by the parents of each of those RRCs, approved by the ACGME in 1985, and became effective in 1986. At the same time, the ABOS, the American Board of Surgery, and the American Board of Plastic Surgery presented a plan for a Certificate of Added Qualifications in Hand Surgery to their parents and to the American Board of Medical Specialties. This was approved, and the first certification examination was administered in 1989.

The ACGME agreed to accredit fellowship programs in orthopaedic surgery that did not lead to certification of the individual. Accreditation of fellowships in pediatric orthopaedics became effective in 1986. Since that time, special requirements have been approved for fellowships in adult reconstructive orthopaedics, foot and ankle orthopaedics, musculoskeletal oncology, orthopaedic sports medicine, orthopaedic surgery of the spine, and orthopaedic trauma. Because of the concerns of the orthopaedic surgery community, the only Certificate of Added Qualifications has been in hand surgery. Subspecialty certification in orthopaedic sports medicine is planned.

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Time-Limited Board Certification

The ABOS and others had been concerned regarding orthopaedic surgeons maintaining the knowledge and skills necessary to practice quality orthopaedic surgery during the years after the certification examination. Family Practice began their certification process with a time-limited certificate. Other specialties were beginning to limit their certificates, and the American Board of Medical Specialties pushed for all boards to issue time-limited certificates. The ABOS began discussing recertification in the 1970s and in 1983 offered the first voluntary recertification examination. Recertification was unpopular in the orthopaedic community, and the voluntary process did not have the desired effect. In 1986, all primary certificates issued by the ABOS were limited to 10 years. Multiple pathways for recertification, including written examination, practice-based examination and, for a time, a practice audit, were offered. In addition, the recertification process required 120 credits of Category 1 Continuing Medical Education and peer review. I think time-limited certificates and re-certification provide a degree of accountability to our patients, our colleagues, and society.

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DISCUSSION

The RRC currently directs the residency program regarding faculty, educational content, and facilities that must be available for the education of an orthopaedic resident. The ABOS sets the educational requirements necessary to prepare the individual to deliver quality care to patients with musculoskeletal problems and then tests that individual to determine whether he or she has learned and correctly applied the knowledge in patient care. When the ABOS needs to make changes, proposed changes are sent to the American Board of Medical Specialties (ABMS) for final approval. The eligibility requirements for the ABOS and the RRC are not worded the same and the specificity varies, but they are compatible with each other.

The scope, techniques, and knowledge in the field of orthopaedic surgery have changed greatly since the beginning of certification and accreditation of residents and residency programs. Of necessity, changes in the educational requirements for residency programs have continued to be made. Examples include the addition of the clinical competencies: formal program evaluations of faculty, residents, and program content; bio-skills training, including arthroscopy, joint replacement, and applications for internal fixation; research experience; limitation of work hours for resident staff; recording of uniform case logs by all residents to monitor resident and program experience; and restructuring of postgraduate year 1 to provide improved education in relation to orthopaedic surgery with full control resting with the Program Director of the Orthopaedic Residency Program. The continual modification and upgrading of resident education and of methods for determining competence of the orthopaedic surgeon are the responsibility of the RRC and ACGME and the ABOS and ABMS.

Changes in the Special Requirements for Residency Programs and changes in the ABOS requirements take considerable time, and many people contribute to the end result. I have been involved with the RRC and ABOS during a period of 34 years, and I believe the deliberations and actions of the orthopaedic surgeons on these organizations have served patients with musculoskeletal problems and orthopaedic surgery in an exemplary manner.

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Acknowledgments

I thank Stephen Nestler, PhD, Secretary, Residency Review Committee for Orthopaedic Surgery, for making the minutes of the RRC, the past Graduate Medical Education Directories, and his “History and Organization of the ACGME” available to me; G. Paul DeRosa, MD, Executive Director of the American Board of Orthopaedic Surgery, for making the minutes of the Board Meetings available; Thornton Brown, MD, Robert H. Brashear Jr., MD, and Paul H. Curtiss, MD for “A Centennial History” (published by the AOA in 1987); and Jack K. Wickstrom, MD, for his “History of the American Board of Orthopaedic Surgery: 1934−1984.”2

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References

1. Flexner A. Medical Education in the United States and Canada: a Report to the Carnegie Foundation for the Advancement of Teaching. Carnegie Institute, New York, 1910.
2. Wickstrom JK. The Classic. Fifty Years of the American Board of Orthopaedic Surgery. Clin Orthop Relat Res. 1990;257:3-10.
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