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Challenges to Orthopaedic Resident Education

LaPorte, Dawn M., MD; Tornetta, Paul, MD; Marsh, J. Lawrence, MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: June 15, 2019 - Volume 27 - Issue 12 - p 419–425
doi: 10.5435/JAAOS-D-18-00084
Review Article

Orthopaedic resident educators confront many important issues. This may be the most challenging time yet for orthopaedic education. A survey of program directors and chairs aimed to identify the major challenges in orthopaedic education. Many issues were identified, and the following four major themes emerged: (1) loss of professionalism, (2) too much emphasis on procedures, (3) lack of clinical experience, and (4) challenges with external oversight. Professionalism in taking care of patients may be compromised by work-hour limitations and affected by generational differences. Limitations to progressive, graduated responsibility include internal and external factors, resulting in a lack of opportunity. Overemphasis on case volume fosters a training environment where technical skill is seen as most important and can detract from teaching the basic principles of being a doctor, including shared decision making. This paper explores these major challenges to orthopaedic resident education in 2018. Substantial changes will be required to address these challenges, but better understanding of the issues they face should help educators identify, minimize, or ideally avoid threats to optimal resident education.

From the Department of Orthopaedic Surgery (Dr. LaPorte), The Johns Hopkins University, Department of Orthopaedic Surgery (Dr. Tornetta), Boston University, Boston, MA, and Department of Orthopaedics and Rehabilitation (Dr. Marsh), University of Iowa Hospitals and Clinics, Iowa City, IA.

Dr. LaPorte or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Association, American Society for Surgery of the Hand, and Ruth Jackson Orthopaedic Society. Dr. Tornetta or an immediate family member has received IP royalties from Smith & Nephew. Dr. Marsh or an immediate family member has received IP royalties from Zimmer Biomet and Tornier; has stock or stock options held in FxRedux; and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery, Inc.

Every generation of educators has faced important issues, but this may be the most challenging time for orthopaedic education.1 A survey of 12 program directors or chairs asked them to identify the major challenges in orthopaedic education faced by programs. As expected, educators responded with a wide set of important issues. However, four major themes emerged, which are (1) loss of professionalism, (2) too much emphasis on procedures, (3) lack of clinical experience, and (4) challenges with external oversight. These issues have some overlap but are distinct enough to be discussed separately. This article is a combination of the opinions of the survey respondents and the authors. Where possible, we have also referenced the content to other reports in the literature.

Professionalism in taking care of patients is based on ownership of all aspects of the patient's experience. Work-hour limitations, which now begin in medical school, teach a shift-work mentality, which detracts from professionalism. The loss of professionalism may also be fostered by the highly specialized care present in most training environments. For example, interns are taught to call consults instead of to solve problems. Residents are permitted to consider patient issues outside their narrow scope as “not my problem.”

A focus on technical proficiency over diagnostic acumen is eroding the concept of graduated responsibility commensurate with patient care experience. Reasons for loss of graduated responsibility include increased pressures on faculty for clinical and research productivity, lack of support for teaching, lack of training as educators, and depersonalization with electronic medical records. This loss of autonomy—in the operating room and in the clinical and emergency department—compromises trainee education. One cannot learn medicine simply by watching. Additional challenges to resident education are posed by the accreditation and certification bodies that provide external oversight of resident training. The orthopaedic Residency Review Committee (RRC) focuses on case volume and has required case minimums and procedure-based milestones. Emphasis on case logs further fosters the attitude that technical skill is most important. The emphasis on case numbers and procedures can detract from attention to the most important decision a surgeon needs to make: when to be in the operating room. Trainees should be taught basic principles of being a doctor, the importance of nonsurgical treatment, whom to operate on, informed consent, shared decision making, and the value of rehabilitation before and after procedures. The focus in our surgical educational system on training residents to become proceduralists has detracted from these important principles.

This article further explores these major challenges to orthopaedic resident education in 2018. Substantial changes will be required to overcome these challenges, but a better understanding of the issues they face should help educators identify, minimize, and ideally avoid threats to optimal resident education.

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Loss of Professionalism

Work Hours and Shift-work Mentality

Duty-hour restrictions based on the fear of fatigue leading to error have been in place for more than a decade. One unintended consequence is the subliminal message that medicine is a job of shifts rather than a profession of obligation and responsibility.2 This relatively new way of approaching patient care has become more evident because duty-hour restrictions are now present in medical schools. Some schools do not allow their students to stay overnight to work. These rules and requirements cause medical students to see medical practice as a series of shifts after which they are “off.” Over the past several years, the word “shift” has been used more and more often in residency applications and in discussions with students about their experiences. This has resulted in a loss of ownership and more of a “shift worker” mentality.3 A transition from shadowing, which is appropriate for medical school experiences, to ownership must occur as soon as possible during residency training, and this transition is made difficult in the current environment. Shift work does not promote the strong sense of responsibility to a patient, which is needed in our profession. Residents are required to go home when they are post-call, and they lose the connection to the patients they evaluated, diagnosed, and admitted, possibly for surgery the following day. The importance of continuity of care is devalued by this strict adherence to duty-hour regulations. Before the implementation of duty-hour guidelines, on-call residents would “own” the patients they admitted and follow them through their inpatient stays and any procedures, developing relationships with them and taking responsibility for their treatment.

Although a “team” approach to care can be beneficial and redundancy can be protective against some medical errors, it makes it too easy to defer things to others and pass along the less “fun” jobs that are as important as the surgery. In a recent review on the future of orthopaedic training, a chief resident is quoted as stating, “… we have noticed with the work-hour restrictions that there is a move toward almost shift-type work for residents …. Sometimes the pride in taking care of that one patient is not always there because you can hand off issues to the next incoming shift.”4

Professionalism with respect to patient care is based on ownership of all aspects of a patient's care and knowledge of the patient's history and social determinants of health. This knowledge, and more importantly, the therapeutic relationship, is difficult if not impossible to achieve in shifts, particularly in acute settings. Our training system now requires more handoffs than were seen in the past because of the restrictions that are present.5,6 At a meeting of the American Orthopaedic Association, more than 90% of participants indicated that handoffs were much more likely to result in medical error than either fatigue or lack of knowledge at the resident level.7 Despite advances such as the I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver) system for handoffs, this is still the riskiest part of care.8 This may be magnified at larger centers where residents cross-cover other services and are not given a specific handoff for all patients. In addition, it is attractive for residents nearing the end of their “shifts” to defer the less enjoyable parts of care to the next team or person, potentially delaying important aspects of care. Although a team approach may allow for redundancy in care, it also allows a lack of personal responsibility. This makes taking care of patients less stressful on any one member, but if specific components of care responsibility are not clearly defined, it also allows more to fall through the cracks. For instance, when someone other than the primary provider completes a discharge summary and instructions, it is easy for details to be lost, especially in complex patients. The more people involved in the patient's care and the more handoffs that occur, the more opportunities there are for translational errors to be made in documentation.9 These errors can result in worse outcomes for patients.

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Lack of Ownership

Although many issues that face current surgical education are inherent in the system, a sense of ownership is something that needs to become inherent in the trainees. Lack of ownership of their own education is a concern with the current generation of trainees. In the past, a resident who did not know something when asked or when caring for a patient would go home, read, and try to avoid this embarrassment in the future. Now, the attitude of some residents is that the “program” is responsible and it did not teach them appropriately. This is a reversal of accountability that may follow from the current emphasis on work-life balance and duty-hour limitations. Less time working often means less time reading at home as well. Gen Xers seem to deal with excessive work demands by seeking balance and perhaps choosing not to do it all.10 Generational differences exist in perception of service and education.11-13 Service and education are tied together, and learners need to understand and accept that the two are closely associated and equally important. Often no line is present between service and education because almost all functions that provide care to a patient are educational and must be learned. With the current work-hour limits, many programs have ancillary help for residents, and unfortunately, these providers assume important roles almost exclusively. In some programs, discharge summaries, physical therapy orders, and medicine reconciliations are not done by the residents, leaving them ill-prepared to act on their own when needed.

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Overemphasis on Procedures

Arguably, time spent in the clinic is the most valuable educational experience to all trainees. There, they see the proper way to approach a problem, the many subtleties of the physical examination, and most importantly the shared decision making that occurs in choosing a treatment course. Finally, they see the end product, the outcome that the patient achieves, which should be the focus of all of our decisions. Although some treatments may be episodic and emergent, most are not, and the relationship built with patients is crucial. Patients must be able to rely on accurate and, most importantly, consistent information to obtain the best outcomes. It is common that senior surgeons see patients in the office or clinic multiple times to develop a relationship with them and to fully understand their needs to develop the most effective therapeutic plan. The most important decision for a surgeon to make with a patient is whether to operate; it is the basis of any surgical practice. One's understanding of a patient's goals, the patient's ability to follow instructions, and the patient's social supports, medical history, and social determinants of health is critical to arrive at the best shared decision for treatment. The RRC has had a longstanding requirement for one half-day in clinic per week and recommends a full day. However, fulfillment of this requirement is difficult to track, and the most recent changes in program accreditation are to place more value on case logs, reflecting an assumption that a certain number of cases is needed to achieve proficiency.14 Within the context of the current duty-hour restrictions, when surgical case logs are tracked as an important component of residency accreditation, clinic time is sacrificed.

The Accreditation Council for Graduate Medical Education (ACGME) has chosen procedural assessment for good reasons; it is an objective metric, and procedural experience is important. The RRC has required minimums in key procedures, resulting in some programs needing to adjust rotations to ensure adequate experience. Clearly, some minimum surgical experience is needed, but more important than performing a 20th intramedullary nail placement, or a fifth ankle fusion, is teaching the concepts and principles around how to do any nail placement, or any fusion. Many of the procedures that we now perform were not available or are performed completely differently than they were even 10 years ago. Our training programs must focus on general skills and principles rather than specific procedures because only this approach will position residents for success in adapting to changes in a career that involves lifelong learning.

The emphasis on procedure-based training has the potential to deemphasize the most important part of obtaining the best result for the patient, which is the decision making, which begins at the initial evaluation and continues through postoperative rehabilitation. For most surgeons, nonsurgical treatment is used more commonly than surgical care. If we expect our trainees to be able to make good decisions, they need to see the full spectrum of practice. For example, if the “sports” resident is assigned to the operating room with three surgeons to achieve the required “numbers” of cases, the resident may not see the 10 patients being treated nonsurgically but only the one who ends up in the operating room. The resident misses out on the development of a strong therapeutic relationship with that surgical patient as the patient tries nonsurgical measures before surgery. The resident will not see the many patients who do well without surgery, which may be the most important lesson of all.

Finally, it is easy for program directors to focus on case logs, forgetting how valuable and necessary clinic time is for the education and maturation of a surgeon. Additionally, trainees are often more excited to go into the operating room than into the clinic, so if this critical component of their education is lacking, they are less likely to recognize it or point it out.

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Lack of Experience and Opportunity

In the current environment of resident training, a lack of resident experience challenges optimal education. We all learn from experience, and less experience for residents means less competent graduates. It is not immediately intuitive why, at a time when the numbers of orthopaedic visits and surgical procedures in most teaching hospitals are increasing, that resident experience would decrease. Measuring experience is difficult. Orthopaedic case logs indicate that, on average, residents are participating in more surgical cases than ever before. Despite this evidence, clear trends strongly suggest that the types of experiences that lead to competence in general orthopaedics have decreased and continue to decline.1 These trends threaten resident education and the degree to which residents are competent at the end of their training. Several important factors contribute to this trend. In this section, we explore reasons why residents are obtaining less experience during modern surgical training.

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Loss of Graduated Responsibility

Graduated responsibility is the core of surgical education and has been since the turn of the 20th century. William Halsted is widely credited with the concept of resident surgeons learning through graduated responsibility as part of actual patient care.15 In the current training, the system of Halsted, based on graduated responsibility, is stressed; residents may have more experiences but less responsibility, and particularly less independent experience that is necessary to learn the skills and aptitudes needed for independent practice.1 Optimally, as resident surgeons progress through their training years, they should have increasing responsibility for patient care and decision making and increased independence in performing surgery. They need to learn how to solve problems both inside and outside the operating room, and learning is facilitated by doing. However, in most operating room environments with residents in training, strict supervision is maintained until the end of residency. It is unreasonable to expect that total supervision will change seamlessly to total independence the day a resident finishes a training program.

Less independence and less graduated responsibility than in the past are facts of current training for many reasons.16,17 Demands of the public and Medicare billing regulations have resulted in a requirement for increased direct supervision. This in turn compromises the resident's transition to independence and limits opportunities for autonomy and graduated responsibility. The classic Halsted training model, “See one, do one, teach one,” is no longer valid or acceptable. Although some change is good, the opportunity for graduated responsibility, increasing as the trainee gains skills and knowledge, is important to facilitate autonomy and improve problem-solving skills, leadership, confidence, and competence.1,18 A senior resident with an appropriate knowledge base and technical skills should be able to make a diagnosis, develop and execute a treatment plan, and manage the patient through the hospital stay.

Healthcare delivery, as it is practiced in major training hospitals, has changed in many ways during recent decades, and many of these changes have had a negative effect on the graduated responsibility system. These changes include pressure on faculty for throughput, compensation based on productivity, and institutional pressure for surgical volume. These pressures leave little time for junior residents to acquire basic skills and even less time for more senior residents to have graduated independence. Indeed, in most operating rooms, true graduated independence has disappeared because faculty must be present for key portions of procedures to allow them to bill for services. Traditional city/county teaching hospitals and teaching services are almost a relic of the past.1

The patient quality and safety movement has increased the need for faculty surgeons to be closely involved in most aspects of surgical care, particularly during surgical procedures. Though laudable and important, this practice rarely leads to more responsibility for residents and frequently contributes to the previously described issues that decrease resident responsibility for patient care. How often do residents solve intraoperative problems independently? How often do they indicate surgery? How often do they make decisions regarding the management of complications? One can argue that in the current quality and safety environment, residents cannot and should not be independent during critical points in patient care. Although this may be the mandate, one can argue that patients who will be cared for by these future clinicians would want them to have had those experiences.

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Lack of a Curriculum

Lack of a clear, defined, and detailed orthopaedic curriculum leads to less experience in basic procedures for orthopaedic residents. Orthopaedic surgical training has very little structure or mandated requirements for experiences that residents must have. The American Board of Orthopaedic Surgery (ABOS) requires 12 months of training in adult orthopaedics, 12 months in trauma, and 6 months in children's orthopaedics.19 These broad requirements provide little direction and no detailed curriculum. Residents' time is often allocated according to the subspecialty distributions of the faculty in their training programs. A high degree of faculty subspecialization at teaching hospitals exists, which results in countless resident hours spent providing support for these highly specialized services. Residents spend correspondingly less time performing general orthopaedic procedures for the type of patients encountered most frequently in general practice.1 The trainees gain experience, but is it the right or the best experience if the goal is to produce a competent and capable general orthopaedic surgeon?

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Other Reasons for a Lack of Resident Experience

There are other reasons that residents lack experience. Do work-hour restrictions lead to less resident experience?20 The obvious answer is “yes.” With the advent of work-hour rules enacted across the country by the ACGME in 2003, “80 hours,” “transitions in care,” and “one day in seven free” have become standard parts of the lexicon of resident training.21,22 To the extent that hours in the hospital equate to experience, fewer hours means less resident experience. However, resident-reported operative case logs in orthopaedic surgery have increased gradually since the advent of mandatory reporting. Despite this, unintended consequences of these regulations include fewer hours available for learning, for deliberate practice, and for continuity of care. In turn, residents have less time in the operating room—an estimated loss of 6,684 hours of residency training.23 In addition, because the residents have become fully immersed in rules that limit their work hours, there is less “extracurricular learning” (eg, reading at home or practicing skills in the laboratory after hours). This is an important lost opportunity to expand on and augment the learning gained from patients and experiences earlier that day and to prepare for upcoming surgical procedures.

Residents spend substantial time in nonproductive effort. Electronic medical records and documentation requirements are burdensome for all clinicians, and in teaching hospitals, these burdens are often disproportionately borne by residents.24 Subspecialty fellowships in orthopaedic surgery have grown substantially.25 Although the interaction between residents and fellows can be managed successfully, some inevitable competition is noted for cases, for faculty time, and for responsibility in the patient care experience. Similarly, the number of mid-level care providers has grown markedly.26 These providers have become an increasingly important part of orthopaedic practice, and this has affected the learning environment in academic and other training departments. Mid-level providers can unburden residents of some noneducational activities, but, similar to fellows, they may also compete with residents for faculty time and may substitute for residents, decreasing resident experience.27

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Challenges with External Oversight

In addition to losses of professionalism and opportunity, which may be considered internal factors, there are challenges to resident education posed by external influences. The Orthopaedic Surgery RRC, under the ACGME, is the regulatory body that provides accreditation and external oversight for orthopaedic training programs. The goal of the RRC is to improve the quality of health care and graduate medical education. In an effort to maintain the highest standards, all programs now undergo yearly review by the RRC. However, the review process has been reduced to oversight of procedure numbers (case logs), resident opinion (resident surveys), board pass rates, and self-reported scholarship.14 If a program is below the specified threshold in one area, that program will be issued a citation. To maintain accreditation, residency programs are required to demonstrate that their trainees perform a sufficient number and variety of surgical procedures. Similarly, required resident “case minimums” must be met before graduation from training. Work hours and educational environment are emphasized on the survey. Performance on multiple-choice, in-training examinations and board pass rates are extremely important. Residents spend countless hours reviewing practice questions, an activity of uncertain value to learning patient care competencies and one that is likely overemphasized in the current educational environment.

Other important areas of resident education, which are more difficult to objectively measure, have been correspondingly deemphasized. Whereas there are strict criteria available for case volumes, there is no quantitative requirement for or direct attention given to quality of patient care, understanding of disease, or decision making. Furthermore, the ACGME and the American Board of Orthopaedic Surgery have developed “milestone” diagnoses/procedures and require serial evaluation of each of these topics. Milestones are a uniform assessment method that has been adopted nationally, which is laudable. However, these milestone topics and the procedural minimums do not cover the breadth of topics and procedures residents will need to master for general practice.28,29 Although it is important to ensure appropriate patient care and medical knowledge, less assessment or emphasis exists in other critical areas, such as continuity of care or decision making. These requirements encourage training programs to focus on meeting case numbers and milestone targets. Conference time and clinical experience, although still required, are deemphasized because they are more difficult to measure. Thirty-two milestones are required for patient care and medical knowledge, with only 9 covering the other 4 competencies of professionalism, systems of practice, practice-based learning, and communication skills. The ABOS defines the educational criteria for residents to achieve board certification, but the board does not currently have any requirements that improve any of the issues described earlier. A very loosely defined set of experiences exists, which the residents must have before taking their part 1 medical knowledge examination.1 As candidates for board certification progress into practice, they are assessed by surveys in a variety of patient care, professionalism, and communication competencies. Their part 2 practice-based examination also assesses these other competencies and does not focus only on knowledge and skill. However, the board does not have similar requirements for in-training assessment and performance of residents. Residents are deemed eligible for the board examination on the basis of program director attestation alone.

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Notable challenges to resident education involve the difficulty of assessing and emphasizing various aspects of professionalism, overemphasis on surgical procedures, loss of valuable experience, and challenges with external oversight. It is our responsibility to instill a fierce sense of professionalism in our residents. This means that they should feel the full weight of the patient's outcome from start to finish. The current environment of procedure-specific training, procedure-specific milestones, limited work hours, more handoffs, and diminished clinic time does not serve our trainees well.

The patient care experiences that residents are now having are not optimal. Graduated responsibility in patient care and surgical procedures is required to develop the confidence and skills necessary to be a competent surgeon; no substitute exists. Despite abundant patients and cases, orthopaedic residents have less valuable experience than in past training environments. Experience leads to competence; less experience means less competence. The issues that lead to this are numerous and include pressures on faculty, the patient safety movement, lack of a curriculum, and the subspecialization of orthopaedic surgery.

Unfortunately, the current oversight of resident training provided by the ACGME through the orthopaedic RRC and the ABOS does not directly address these issues and, in some ways, with emphasis on case logs and multiple-choice examinations, is fostering these problems. Some improvements may be possible with modest changes, including decreased emphasis on case numbers, formal evaluation and assessment of professionalism and decision-making ability, and possible development of a formal curriculum for orthopaedic trainees. The ABOS and ACGME are in discussions about implementing more standardized assessments, some of which would focus on professionalism and communication skills. When orthopaedic milestones are revised (milestones 2.0), there will be an opportunity to increase emphasis in these important areas. Unfortunately, several of the issues identified in this article are deeply embedded in our healthcare system and society.

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Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 11 is level II studies. References 8, 9, 21, 24, 25, and 29 are level III studies. References 1, 2, 3, 4, 5, 6, 7, 10, 12, 13, 14, 15, 16, 17, 18, 20, 22, 23, 26, 27, and 28 are level V.

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

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21. Levine WN, Spang RC III: ACGME duty hour requirements: Perceptions and impact on resident training and patient care. J Am Acad Orthop Surg 2014;22:535–544.
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