The required research rotation in residency: the University of Pennsylvania experience, 1978-1993

The University of Pennsylvania orthopaedic surgery residency program under the direction of Dr. Carl T. Brighton was uniquely structured to require a year of research as part of a 5-year program. This requirement was instituted to foster critical thinking, and not necessarily to produce academic orthopaedic surgeons. Nonetheless, measures of academic productivity of the 127 residents who trained under Dr. Brighton's leadership may be instructive. The purpose of this study was to assess metrics of academic productivity. In addition, the six current and former chairmen of orthopaedic surgery programs who performed research while residents at the University of Pennsylvania were surveyed for their impressions regarding required research rotations. Fifty-nine percent of the University of Pennsylvania residents took faculty positions after training; 75% published a peer-reviewed paper after residency; and 17% are current members of the American Orthopaedic Association. Overall, the chairmen surveyed found great value in their own resident research experience, but none have replicated the Brighton model of residency organization. Only two of the six programs have a research year: at both, this research rotation is in addition to the standard 5 years of clinical education and only at one are all residents required to participate.

An elective research year in orthopaedic residency: how does one measure its outcome and define its success?

The concept of an elective research year during orthopaedic residency training is attractive to residents and faculty involved in graduate medical education. Measuring the success and outcomes of a research residency year remains poorly defined. The goal of this study is to evaluate the role and effect of the elective resident research year. How does one determine or define the "success" of a resident research year? Does the research residency year encourage residents to become clinician-scientists? A previously published questionnaire was mailed out to the 93 residents who completed their orthopaedic residency training between 1976 and 2005. The response rate was 70%. The majority of residents went into private practice (91.2%). In comparing residents with a research year to those without, no difference was noted in residents entering private or academic practice, or completing a fellowship. The research residents had a greater mean number of publications cited in PubMed. The mean number of publications after residency was similar. Exposure to an elective year of research did not appear to positively influence residents to enter a career in academic medicine.

Resident selection and predictors of performance: can we be evidence based?

Selection of orthopaedic residents can be a difficult process; we have endeavored to make it more objective by developing a scoring methodology for screening applications. The purpose of this investigation is to determine if an academic score, using objective elements only, will discriminate among applicants and will correlate with outcomes. Applications to our orthopaedic residency program for 2004 and 2005 were assigned an academic score as a screening tool in the residency selection process. Data was analyzed for the entire group both by gender and whether the applicant had interviewed for the program. Additionally, the applications of program graduates over the past 5 years were retrospectively assigned academic scores, which were compared with outcomes of the training program. Academic scores for applicants formed a generally normal distribution, and residents training in the program generally had higher scores. The distribution of scores for female applicants was similar to male applicants; however, a greater percentage of female applicants interviewed for the program. Scores on the OITE and ABOS examinations tended to parallel academic scores, but faculty ratings of performance in the program showed no difference between those with high and low academic scores. Calculating academic scores makes the application screening process more objective but does not appear to correlate with outcomes of the training program.

Factors in optimizing the learning environment for surgical training

Today's surgeon is required to demonstrate a variety of professional competencies in an increasingly complex environment. Recently, the time available to train this surgeon has started to erode due to external pressures on administrators and faculty. This growing crisis has led to questions about how to optimize learning in the surgical environment. Clearly, to adequately train a competent surgeon in all the required aspects, multiple environments will be required. We must, therefore, look carefully at each environment to maximize its educational potential for each of the competencies. At the same time, however, we must ensure these educational environments and opportunities integrate into a coherent and systematic program of training that is flexible and adaptable to the individual needs of the trainees. This paper describes two broad areas that must be at the forefront of the community's thinking as we strive toward this goal: the irreplaceable value of a mentor and maximizing the potential of optimal challenge points in learning.

What we don't know we are teaching: unveiling the hidden curriculum

In addition to the intentional teaching of knowledge and skills by surgeons to their trainees and protégés is the unintended, often unrealized transmission of implicit beliefs, attitudes, and behaviors through a process called the hidden curriculum. The hidden curriculum is a function of implicit values held by the institution as a whole, and the individual surgical educators and allied health professionals working in the trainee's learning environment. It has been argued the hidden curriculum plays a central role in the development of professionalism, but it may also play an important role in inadvertently deterring good candidates from considering orthopaedic surgery as a career. We review the importance of attending to the messages we transmit to our trainees, protégés, and junior colleagues as we strive to develop professional competency and recruit the best into the field.

Effect of duty hour standards on burnout among orthopaedic surgery residents

We surveyed orthopaedic surgery residents and faculty from two university training programs to quantify quality of life measures including burnout, general health, and relationship issues. Residents exhibited high levels of burnout and emotional exhaustion but only average levels of personal achievement, while faculty showed lower levels of burnout and emotional exhaustion with above average scores for personal achievement. Resident burnout was positively correlated with number of hours worked while faculty hours worked was inversely related to burnout. The survey was readministered two years after implementing the Accreditation Council on Graduate Medical Education guidelines on residency duty hours. At this time resident scores for personal accomplishment had improved, while scores for emotional exhaustion showed a strong trend towards decreasing, and depersonalization scores also showed a possible trend towards decreasing. Resident duty hour limitation was associated with improvement in objective measures of burnout.

Mentoring during residency education: a unique challenge for the surgeon?

A mentor serves as role model, counselor, and advocate for an understudy or protégé. The art and science of mentoring have been investigated most thoroughly in the educational literature, yet there are unique situational and individual considerations in the surgical arena that may warrant special consideration. The general attributes of successful mentors are not foreign to academic surgeons but may require deliberate cultivation to optimize mentorship in the context of academic medicine. Moreover, the stages of productive mentoring may be counter to the learned adaptive behaviors and instinctive personality traits of some accomplished surgeon educators. Indeed, examples of failed mentorship are common in our medical centers and, specifically, in surgical training programs. The behavioral adaptation that supports surgical decision-making under conditions of incomplete data and unusual stress often devalues succession planning and derivation of satisfaction from the success of other members of the team. Accordingly, fostering effective mentoring relationships in academic surgery will require a concerted effort to develop appropriate behaviors conducive to the mentoring process. The personal and professional growth of our students as well as the succession planning for our specialty are dependent upon the successful creation of an environment conducive to mentoring in academic orthopaedics.

Professionalism and virtues

Professionalism is one of the six core competencies of both the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). It is being taught and discussed at the medical school level as well as throughout residency and continues during the lifetime of an orthopaedic surgeon. This paper will review its definition as well as the virtues that are necessary to sustain medical professionalism.

A quantitative composite scoring tool for orthopaedic residency screening and selection

The ability to accurately screen and select orthopaedic resident applicants with eventual successful outcomes has been historically difficult. Many preresidency selection variables are subjective in nature and a more standardized objective scoring method seems desirable. A quantitative composite scoring tool (QCST) to be used in a standardized manner to help predict orthopaedic residency performance from application materials was developed. In 64 orthopaedic residents, four predictors (United States Medical Licensing Examination [USMLE] Part I scores, Alpha Omega Alpha status, junior year clinical clerkship honors grades, and the QCST score) were analyzed with respect to four residency outcomes assessments. The outcomes included three standardized assessments, the orthopaedic in-training examination scores (OITE), the American Board of Orthopaedic Surgery (ABOS) written and oral examinations, and an internal outcomes assessment, attainment of satisfactory chief resident associate (CRA) status. Collectively, the QCST score had the strongest association as a predictor for all three standardized outcomes assessments (p < 0.001). Honors grades during junior years clinical clerkships was most strongly associated with satisfactory CRA status (p < 0.001). A composite scoring tool that is an effective predictor of orthopaedic resident outcomes can be developed. Additional work is still required to refine this scoring tool for orthopaedic residency screening and selection.

Continuing competency in orthopaedics: the future of recertification

The American Board of Orthopaedic Surgery implemented a recertification program in 1986. This process has expanded to include a number of examination pathways that take into account subspecialty practices. Over the past two decades, general competencies of physicians have been defined and programs for evaluation and maintenance of these competencies developed. In an effort to have a more continuous process rather than episodic examinations only, and stimulate lifelong learning and practice improvement, recertification is now undergoing transformation to a Maintenance of Certification program. Maintenance of Certification as a process will emphasize ongoing self-assessment and lifelong learning, with required components occurring more frequently during the 10 year recertification cycle. Patient satisfaction and communication surveys will be incorporated to provide feedback to physicians to improve practice performance. Case list reviews, with a focus on patient safety measures, will also be a new addition to the process.

Resident selection: a key to the future of orthopaedics

Recognizing the challenges presented in the process of resident selection, in 1981 the American Orthopaedic Association formed a Steering Committee on Resident Selection. This Committee was charged with studying the processes involved in the selection of orthopaedic residents and developing guidelines and making suggestions to program directors. The activities of the Committee focused on five areas: (1) the mechanics of resident selection; (2) the assessment of cognitive skills; (3) the assessment of motor ability; (4) the assessment of noncognitive factors (the affective domain); (5) the assessment of "dropouts." The Committee made the following recommendations to help program directors in the selection of residents: (1) use of a standardized application form; (2) full disclosure to applicants; (3) careful selection of candidates to be interviewed; (4) careful planning and implementation of the interview and visit; (5) broad faculty representation and discussion at time of selection; (6) due diligence when necessary. We still believe these criteria important in resident selection.

The effect of work hour restrictions on the education of orthopaedic surgery residents

In 2005 the Academic Leadership Group of the American Orthopaedic Association surveyed orthopaedic program directors, chairs, and members of the Resident Leadership Forum to gather information about the effect of the Accreditation Council for Graduate Medical Education work-hour restrictions on resident education. We compared these results with a similar survey performed 2 years ago. Ninety-four program directors and chairs and 59 senior residents responded to this survey. Overall, the respondents thought the duty hour restrictions had a negative impact on orthopaedic residency education but less so than in the previous survey. This conclusion was based on perceived negative effects on professionalism, resident operative experience, continuity of care, and increased workload for the faculty. Senior residents who worked before and after the work-hour limitations were instituted were more concerned about the negative effects than junior residents. Residents did seem more rested and content but not better prepared or necessarily more attentive. Respondents were not of the opinion resident performance had improved as measured by perceptions of performance on standardized tests. Orthopaedic departments had adapted to the work-hour limitations by scheduling night float rotations, converting in-house call to home call, and by hiring additional personnel in the form of physician extenders.

The 80-hour duty week: rationale, early attitudes, and future questions

There is considerable concern and much evidence resident fatigue results in medical errors, some of which have serious consequences. Similarly, fatigue causes poor health in house-staff and places these individuals at greater risk for personal injuries, including motor vehicle accidents. These circumstances led the Accreditation Council on Graduate Medical Education to develop and, on July 1, 2003, to implement guidelines for all residency training programs limiting the time of in-house duty to 80 hours per week. Surveys of orthopaedic residents by the American Academy of Orthopaedic Surgeons, before and right after implementation of these new duty rules, confirm housestaff were working longer than 80 hours before July 2003 and are largely in compliance since that date. Residents generally approve of these changes and are personally happier, but also express concern for a loss of continuity of care and reduced exposure to operative cases. It remains to be demonstrated whether these new rules will improve patient care, enhance housestaff well-being, or influence education.

Predicting the technical competence of surgical residents

I describe an approach to predicting competence in technical skills for the purposes of resident selection. To demonstrate a predictive relationship, it is necessary to use measures that exhibit variation, reliability, and validity. There is little evidence that such measures are routinely used in the process of selecting residents. I argue that the selection of assessment instruments in the predictor domain must be guided by relevant theoretical considerations, while assessment in the surgical domain must make use of more objective and reliable instruments than is currently the practice. I present a brief summary of research on predicting operative technical competence.

The need for research training in orthopaedic residency education

Orthopaedic surgery residents should be exposed during their clinical training to the processes of creativity and innovation that are the basis of research. The definition of a research experience for surgery residents should be broad and include not only traditional bench research in a basic science environment but also translational and clinical research to move innovation from bench to bedside and validate its value in a scientific manner. Additionally, there are enormous opportunities for surgeons to study healthcare delivery and policy and to develop new approaches to educating colleagues, other medical personnel, and patients. The question that must be addressed is how can the knowledge and human resources residing in orthopaedic surgery best be used to meet the challenges future residents will face as healthcare undergoes profound changes? How these issues are managed in a rapidly changing environment is the critical issue and the challenge faced by surgical training programs wishing to remain viable and provide trainees with the opportunity to adapt and be successful in the future. What is state of the art today will not be tomorrow and unless trainees are encouraged and taught to be creative and innovative they risk becoming surgical dinosaurs.