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Reviews: The Training Room

“Virtual” Boot Camp: Orthopaedic Intern Education in the Time of COVID-19 and Beyond

Bhashyam, Abhiram R. MD, PhD; Dyer, George S. M. MD, FACS

Author Information
Journal of the American Academy of Orthopaedic Surgeons: September 1, 2020 - Volume 28 - Issue 17 - p e735-e743
doi: 10.5435/JAAOS-D-20-00559

Abstract

Simulation-based training has an increasing role in basic orthopaedic surgical skills education for orthopaedic residents.1-3 This is particularly relevant for PGY-1 residents, and the American Board of Orthopaedic Surgeons (ABOS) has mandated a standardized structured skills curriculum for PGY-1 residents focused on emergency care and initial training in basic skills of orthopaedic surgery.4 To meet this requirement, many residency programs have created intensive skills courses and teaching programs for PGY-1 residents based on of the ABOS modules or previous literature. These “boot camps” are largely in-person with a focus on boosting cognitive knowledge and skills training.3-6

Unfortunately, the emergence of COVID-19 as a viral pandemic in early 2020 resulted in notable changes to the daily practice, workflow, and education of orthopaedic residencies internationally.7-10 In particular, social distancing, residency restructuring, and redeployment to other services has increased heterogeneity in schedules and made the in-person gathering of trainees for education increasingly challenging.7,9 These changes may last until 2024 based on some mathematical models, resulting in notable disruptions to orthopaedic education, especially for junior residents.7,11

In these circumstances, creative solutions using newer teaching techniques or technology (eg, the flipped classroom model, teleconferencing in place of in-person lectures, procedural simulation, or the facilitated use of surgical videos) are needed to maintain quality training to build domain-specific skills and knowledge.8,10,12 However, although there have been numerous articles on resident education and simulation, an integrated curriculum that facilitates asynchronous remote learning is still lacking, particularly for procedural skills training.2,3,5,6,13-20 This is especially true during COVID-19, where these modules must allow for social distancing and altered clinical workflows, even within the same clinical department or hospitals.9,10 In this study, we describe how we converted our in-person PGY-1 skills course into a “virtual” boot camp that may be easily implemented by program directors throughout the country. Our curriculum was based on validated training modules and existing ABOS guidelines that should translate easily in different settings.3,4 Lessons learned from the experience and potential areas for improvement in the use of newer technology to teach cognitive knowledge and skills modules is highlighted with the hope that this can be useful to other orthopaedic residency programs during the pandemic and also beyond.

Course Design

Conceptualization

In our department, PGY-1 residents rotate through clinical services that fulfill program requirements as mandated by the ABOS. Since 2013, we have run a “protected” 1-month basic surgical skills training program for PGY-1 residents based on Westerlind et al and the ABOS Modules.3,4 In 2020, COVID-19 forced several changes. Because work schedules were altered, learner schedules became increasingly asynchronous (both in time and location). In addition, because of social distancing guidelines, physically gathering was neither logistically possible nor safe.

Curriculum Development

Our goal was to create an asynchronous learning platform to allow PGY-1 residents to develop basic orthopaedic knowledge and skills required for emergency care and progress from basic to more advanced surgical procedures. We preserved some elements of traditional learning, given that interns are novice learners,21 but the key differences from our previous efforts were (1) inclusion of low-technology/cost options to create “take-home” kits that could be completed remotely and (2) avoiding the need for controlled environments with assembled learners. Cognitive knowledge and skill topics were defined from needs assessments of our PGY-1 residents, discussion with faculty, and published literature3,4,22 The course was organized by a chief resident, program director, and two program coordinators.

Similar to our “in-person” course, a dedicated curriculum was created for our “virtual” boot camp based on the input of recruited teaching faculty (full schedule available at https://ortho.hms.harvard.edu/virtual-bootcamp). The topics were organized into a modular weekly format that facilitated focused skills development with flexibility in scheduling.4 The four weekly modules were basic skills/hand, sport, trauma, and arthroplasty. All lectures were designed to be presented via videoconferencing software. Each skill module was modified such that it could be completed remotely (eg, at home or in a call room). Modules were selected to minimize the redundancy of equipment and to maximize the ability for use in different exercise programs of increasing complexity throughout the month. All modules were chosen based on the published literature demonstrating efficacy in skills acquisition and were tested before the course.

Course Implementation

Course Structure

During the month, PGY1 residents worked full time in “virtual” boot camp except for cases of redeployment or weekend call. A syllabus was provided 1 month in advance and included goals/objectives, suggesting readings and videos, descriptions of skill modules/techniques/procedures, and information regarding provided supplies and setup.3 Equipment for the skills modules was provided 1 week in advance.

Cognitive Knowledge

Each lecture was organized using a standardized template provided by education specialists at our institution's simulation center. Each lecture included the goal for the session, specific educational objective(s), and a brief content description. All lecturers delivered by faculty or senior residents and conflicts of interest were disclosed per our institutional policy. Lectures were delivered using videoconferencing software (Zoom Video Communications). All lectures were recorded and stored in a Health Insurance Portability and Accountability Act (HIPAA) compliant fashion using an institutional account. Recorded lectures were uploaded to a central repository for viewing by any resident in our program. Problem-based learning was encouraged, given the strong evidence for this learning style for adult learners.22 In addition, when teaching surgical procedures, faculty were encouraged to “walk through” publicly available videos of cases (eg, the AAOS Orthopaedic Video Theater/YouTube/VuMedi) and elaborate on each case structure by structure, decision by decision, and maneuver by maneuver. This type of cognitive stimulation is one of the newest examples of innovation in surgical teaching techniques.23,24 The structured experience of “rehearsing” or reviewing surgery with supervision and feedback helps to build understanding of surgical techniques, especially for junior trainees.13,24,25

Skills Training

Each skills module was designed to be completed at home. As a result, none of the skills sessions required animal or cadaver models, nor did they need additional laboratory staff or personnel. Each skill session typically emphasized low-fidelity training modules of increasing difficulty that could be completed independently with dedicated practice to obtain skills necessary to participate at a basic level in surgical cases.3,20

Skill sessions were organized using a standardized template provided by education specialists at our simulation center (as described above). In addition to a brief content description, each skills module also included the steps and specific equipment required for successful completion. All the equipment was purchased from local hardware stores or online (Tables 1 and 2).26 In each module, learners reviewed supplemental reading and videos before practicing specific skills. During the scheduled session, specific skill exercise programs and elements of good technique were demonstrated using videoconferencing. These demonstrations were recorded and allowed residents to complete skills exercise programs asynchronously without continuous faculty supervision. Informal feedback on observed performance was provided remotely to PGY-1 residents by senior residents at a coordinated time using videoconferencing.

Table 1 - Contents of “Take-Home” Kits Needed for Each Module
Suturing/tendon repair/débridement Drill model
 Skin substitute  Vice grip (x2)
 3-0 ethibond (x2)  Polyvinyl chloride pipe
 2-0 vicryl (x2)  Wood shim
 3-0 nylon (1 box)  Drill
 Adson with teeth  Drill bits
 Debakey forcep  Work bench
 Needleholder  Safety goggles
 Suture scissor Fracture fixation instrumentation
 15 blade  Ex-fix set (divided)
 Banana  Plate and screws
 Orange  Duct tape
 Shoestring (tendon)  Screwdriver
 Paper plate  Drill guide
 Soil  Depth gauge
Microsurgery  Small pointed reduction clamp
 Foam board  Lobster claw
 Thumb tacks  Kirschner wires (x3)
 Blue towel  Sawbones tibia
 Cardboard  Sawbones femur
 Rubber glove  Sawbones forearm
 Small plastic tubing  Sawbones distal tib-fib
 Castroviejo needleholder  Drill + drill bits
 Micro pickup/vessel dilator Splinting
 Fake vessels  Webril
 6-0 nylon  Plaster
 Loupe  ACE
Vascular ligature
 Rubber band nail board
 Rubber bands
 Silk ties
 Hemostat (x2)
 Scissors

Table 2 - Contents of Arthroscopy Kit Required for Module Completion
Basic instrumentation Knot tying
 Laptop  Knot tying board
 Camera  Knot pusher
 Fundamentals of arthroscopic surgery training base  Heavy suture
 Fundamentals of arthroscopic surgery training opaque dome Shoulder
Triangulation  Shoulder module
 Probe  Probe
 Probe numbers Menisectomy
 Screwdriver kit  Menisectomy model
Targeting  Probe
 Horizontal ring transfer  Biter
 Vertical ring transfer Suture passing
 Grasper  Knot tying board
Maze  Suture
 Maze module  Grasper
 Probe  Knot pusher
 Suture passer
 Suture passer model

Each module was based on published literature, and brief descriptions are provided below. Key equipment for each module is presented in Figure 1.

  • Module 1—Suturing and Débridement14,27: The purpose of this module was to practice basic suturing skills (simple interrupted, horizontal/vertical mattress, and deep dermal sutures) and débridement using simulated skin and organic fruit models (oranges and bananas). Emphasis was placed on techniques to obtain wound eversion, minimize soft-tissue trauma, and principles of débridement. Skills advanced in difficulty to the creation of “skin” defects and rotational skin flaps that could be used for coverage.
  • Module 2—Tendon Repair4: The purpose of this module was to practice simple tendon repair using core and epitendinous suturing on a shoestring “tendon” model with multiple longitudinal fibers. Emphasis was placed on atraumatic handling of tissues and techniques of tendon repair. Aggressive handling of tissues resulted in rapid fraying of the tendon model.
  • Module 3—Tying under Tension and Vascular Ligature4: The purpose of this model was to practice principles of knot tying under tension and vascular ligature using a rubber band nail board model with two hemostats and silk ties. Emphasis was placed on the placement of secure square knots using one- and two-handed knots while tying under tension in both a clear field and within a “cavity.”
  • Module 4—Basics of Microsurgery28: The purpose of this module was to practice basic microsurgical suturing techniques using models that advanced from suturing a rubber glove, a small plastic pipe, and concluding with suturing a 3 mm artificial vessel using loupe magnification and microsurgical instruments. Emphasis was placed on minimizing tremor, appropriate handling of instruments, and increasing comfort when operating with loupe magnification.
  • Module 5—Drilling Models: Avoiding Plunging and Getting comfortable with drill sleeve/depth gauge3,14,18: The purpose of this module was to practice the use of basic drill, depth gauge, and screw techniques on wood foam slabs, polyvinyl chloride pipe, and simple synthetic bone models. Emphasis was placed on techniques to avoid plunging and practice of instrument techniques such as the use of a drill sleeve and depth gauge.
  • Module 6—Basic Arthroscopic Skills—Fundamentals of Arthroscopic Surgery Training: The purpose of this module was to introduce and practice basic instrumentation and techniques of arthroscopy using the Fundamentals of Arthroscopic Surgery Training modules.29 Emphasis was placed on techniques of visualization, triangulation, targeting, and arthroscopic knot tying.16
  • Module 7—Basic Splints20,30: The purpose of this technique was to review and practice splinting and reduction techniques for stabilization of fractures commonly encountered in the emergency department.
  • Module 8—Traction Pins3,4: The purpose of this module was to practice the placement of distal femur and proximal tibia traction pins on sawbone femur and tibia models. Emphasis was placed on identifying a safe start point, modifying trajectory, and feeling for a start point that is centered on the bone using the traction pin as an instrument.
  • Module 9—Fracture Fixation14,17,18: The purpose of this module was to practice the use of basic fracture fixation instruments and implants on sawbone fracture models (both bone forearm and ankle). Emphasis was placed on techniques of controlled osteotomy to create fractures, use of clamps to reduce a fracture, and fixation of fractures using provisional and definitive fixation with Kirschner wires/plates/screws.
  • Module 10—Kirschner Wire and Closed Reduction Percutaneous Pinning15,31: The purpose of this module was to review and practice the principles of Kirschner wire fixation in a fractured distal humerus and distal femur model. Common types of Kirschner wires were reviewed (smooth, threaded, etc). Emphasis was placed on techniques related to Kirschner wire configuration (crossed pins and divergent pin fixation) and placement. In addition, closed reduction percutaneous pinning of a femoral neck fracture was simulated in a sawbone femur model.
  • Module 11—External Fixation Principles4,13,18: The purpose of this module was to practice the placement of an external fixator for stabilization of a long bone fracture. Emphasis was placed on the techniques of pin placement, construct design, and approaches to increase construct stiffness. Residents experimented with different pin/bar configurations in multiple small group “break-out” rooms.

Figure 1
Figure 1:
Photograph showing the visual depiction of module equipment: (A) suturing and débridement, (B) tendon repair, (C) basics of microsurgery, (D) tying under tension and vascular ligature, (E) drilling models, (F) fracture fixation/Kirschner wire and closed reduction percutaneous pinning, and (G) traction pins/external fixation principles.

Outcomes

Experience

Based on a previous published model, a survey of PGY-1 learners was completed to assess the course for quality improvement (Table 3 and Figure 2).3 Overall, 100% of residents were satisfied by the course, the modular format, and the “take-home” kits. All residents reported that “virtual” boot camp improved their orthopaedic knowledge base and surgical skills, and 92% of residents thought that it improved their preparedness for the operating room. All residents thought that it should be a permanent part of our resident education, and 92% would have wanted to begin the curriculum from the beginning of their intern year. Logistically, 83% of residents would have also liked to complete modules throughout the year, 75% thought it was helpful to have all of the lectures recorded, and all residents thought that the module quantity and difficulty was “just right.” In general, the course was positively reviewed by learners and involved faculty, but 25% of residents requested more opportunities for assessment.

Table 3 - Results of Quality Improvement Survey Completed by Residents at the Conclusion of the Course
Outcomes: Virtual Bootcamp Resident Survey Satisfaction
Overall 100%
Module format 100%
Was it helpful to have take-home kits? 100%
Did it help your orthopaedic knowledge base? 100%
Did it help your surgical skill set? 100%
Did it improve your preparation for the operating room? 92%

Figure 2
Figure 2:
Chart showing the Likert scale results of quality survey completed by residents; Scale: +++ (very/extremely positive response) to −−− (very/extremely negative response).

Costs

Conversion of our previous in-person course to a virtual curriculum required support from faculty, residents, and support staff. Funding was provided by our department or institution. Because we created “take-home” kits, no direct industry sponsorship was available. The cost of our previous in-person course was similar to a previous study (∼$21,864).3

For “virtual” boot camp, videoconferencing software provided by our hospital was used (Zoom Video Communications; ∼$20 per month). Specific costs for each item were obtained based on the current available prices from local hardware or online stores (Supplemental Digital Content 1, http://links.lww.com/JAAOS/A515). Costs per module per learner were then calculated (Table 4). The arthroscopy module cost was divided among 4 interns, given our course structure; however, this would require a one-time cost of ∼$3,500 at the program level (Sawbones, USA). Costs were further divided into one-time costs (ie, “Start-up” costs) and variable costs (ie, recurring yearly costs to replenish disposable supplies).

Table 4 - Cost (US$) per Module per Learner Based on Current Available Prices (Arthroscopy Trainer Shared Among Four Interns)
Factors Cost/Module/Learner ($) One-time Cost ($) Variable Cost ($)
Suturing/tendon repair/débridement 120 25 95
Microsurgery 71 17 54
Vascular ligature 30 18 12
Drill model 96 94 3
Fracture fixation instrumentation 575 445 130
Splinting 49 0 49
Arthroscopy 856 856 2
Total costa (with arthroscopy) 1,745 1,404 343
Total costa (without arthroscopy) 889 548 341
aItems used in multiple modules were only counted once.

Discussion

Orthopaedic boot camps and skills courses have become more common for PGY-1 residents, but these will require notable changes in the setting of social distancing and clinical workflow changes because of COVID-19.7-10 In this study, we demonstrate one example of a successful transition to a hybrid asynchronous learning system for PGY-1 residents. We maintained a dual focus on improvement in cognitive knowledge and skills training. Teaching sessions were structured using a flipped classroom model and used videoconferencing and “take-home” kits for repeated practice.8,32 The flipped classroom model enabled a mix of asynchronous and synchronous learning because learners could complete parts of the curriculum at their own pace (based on their own understanding or because of scheduling constraints).21,32

Beyond a 1-month intensive course, these modules may also be used for continuous education of residents throughout the year.3 A major benefit of web-based curricula for developing domain-specific cognitive knowledge is flexibility in the setting of time or distance scheduling constraints and the ability of learners to individually pace based on their own knowledge and ability.5,21 Asynchronous learning of domain-specific technical skills has similar advantages. A major benefit of “take-home” surgical simulation is the opportunity for flexible, repetitive psychomotor training in a learner-centered and risk-free environment.14 This is increasingly relevant because of the conflict between service provision and training with time limitations, and modules can be customized based on preferences of individual residency programs.13 Especially for junior residents, multiple studies have demonstrated that bench models allow learners to develop familiarity with the equipment and learn the principles of surgical techniques that transfer well to operating room.13,29,31,33 In addition, previous studies have also shown that these basic skills can often be learned through independent, low-resource-intensive teaching methods28,34

COVID-19 has led many institutions to rapidly adopt video conferencing as a primary means of education.8-10 Because videoconferencing has not been widely used for teaching by most academic orthopaedic surgeons, we reviewed the techniques in other fields for using videoconferencing technology effectively and summarized what we learned during the implementation of this course.10,35 In general, we found it most helpful to enable video for participants and presenters, define expectations for participation, and set a daily schedule. Faculty were encouraged to call on specific learners and wait for longer intervals for their answer. Learners were often on “mute” and needed time to formulate a response. This is especially relevant because physicians often interrupt their own patients within 30 seconds, and in our experience, responses can take markedly longer in an online teaching setting.36 For cognitive knowledge sessions, we encouraged faculty to “split” their screen between their slideshow and a gallery view of learners becaise this simulates a real classroom. In addition, use of the “Whiteboard” feature was particularly helpful to demonstrate concepts. Videoconferencing for skills training sessions was more challenging to plan for as an online activity because these have historically been taught “hands-on.” However, we found that using two cameras or devices was helpful for teaching a new skill (eg, a phone focused closely on the skill task equipment and a computer for interacting with learners). When demonstrating new skills, it was especially important to go slow and intentionally pause at each step for questions or requests for a repeat demonstration. We used “break-out” rooms for small group sessions that enhanced feedback to participants. In these sessions, it was helpful for participants to angle their camera such that the critical steps of the skill activity could be visualized. In addition, at least one evaluating observer had all of the same equipment as learners to lead the learners through individual challenges.

Even before COVID-19, cost was the most substantial barrier to residency program development of simulation-based skills training.6 The cost per intern for our “virtual” boot camp course was $1,700. The overall program cost was markedly cheaper compared with previous reports because we did not use assistants, fluoroscopic resources, or animal/cadaver models.3 In addition, 80% of the cost was a “one-time” cost investment in the first year, and variable yearly costs to replenish supplies was only ∼$343 per intern. None of the modules were sponsored directly by industry, and residency program purchase of equipment allows for continuous use throughout the year without the need for “renting.” This cost and structure is likely to be of notable value for programs with fewer resources both in the United States and internationally.34

Limitations

This report on our pilot experience has several limitations. We present the survey results of a single residency based on satisfaction, but we hope that this is the first step toward building highly effective asynchronous curricula.22,32 Our program had limited formal evaluation of learners, and even informal technical feedback to PGY-1 residents was challenging without a “hands”-on component of teaching, although visual demonstrations by instructors using identical models helped residents overcome challenging learning elements. Regardless, future studies will be needed to develop objective assessments using validated models while harnessing videoconferencing technologically systematically (eg, “break-out” rooms and flexible web cameras).37 These will be essential to testing if previously validated models developed from in-person curricula are also beneficial in a different format/delivery system.5,10 Another concern includes potential loss of skills after a short intensive course.19,38 Although a one-time boot camp style course may not result in effective skill retention when compared with longitudinal training because of a lack of consistent practice, we hope that the creation of low-cost take-home kits will enable residents to continually practice their skills without dedicated space or time constraints. Future studies will be required to demonstrate if skill retention can be improved in this manner. Finally, one element of our cost estimates that was not possible to estimate was faculty time because of unpredictable schedule disruptions from COVID-19.

Summary

In this study, we described how we converted our in-person PGY-1 skills course into a “virtual” boot camp and shared the lessons we learned from our experience. Although our format emphasized social distancing, given the COVID-19 pandemic, this curriculum can be modified based on national and local policy recommendations. Areas for future modification include the incorporation of virtual reality as technology becomes cheaper or the inclusion of cadaver sessions as able.39,40 Education of residents will undoubtedly change because of COVID-19, and orthopaedic educators will have to continually be creative and flexible to ensure quality resident education using newer techniques and technology.8-10,37

Acknowledgments

The authors thank Kaitlin Duffy, Jennifer Duane, Harry Lightsey, Joseph Yellin, Ishaq Ibrahim, Janice He, Charles Carrier, Shalin Patel, and Hemali Bhashyam for their contributions in the preparation, coordination, and implementation of this project.

References

References printed in bold type are those published within the past 5 years.

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Copyright 2020 by the American Academy of Orthopaedic Surgeons.