Three-year experience with an innovative, modular competency-based curriculum for orthopaedic training

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

BACKGROUND

European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS

Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS

Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS

This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Competency-Based Education: Will This be the New Training Paradigm in Plastic Surgery?

The Accreditation Council for Graduate Medical Education created the "Next Accreditation System" in 2013 requiring residents to meet educational milestones based on core competencies over the course of their training. The 6 core competencies include patient care and technical skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Since the traditional time-based model requires a predetermined length of training irrespective of learning style, pace, or activity, a competency-based model is appealing because it refocuses education on deliberate and relevant skills acquisition and retention. Plastic surgery has been slowly transitioning to competency-based education (CBE), thereby permitting residents to learn at their own pace to master each competency. We performed a nonsystematic literature review of the efficacy of CBE and implementation efforts, particularly within plastic surgery. The literature revealed perceived barriers to implementation, as well as the nuts and bolts of implementation. We highlighted possible solutions and training tools with practical applications in plastic surgery. Success of CBE in plastic surgery requires instituting a transparent process that involves continuously piloting multiple assessment tools and a discussion of related costs. CBE may be particularly appealing for trainees focused on further training in craniofacial or pediatric plastic surgery after completion of an integrated or independent training program in plastic surgery to allow them to focus on their career interests once competence is achieved in the core skills required of a plastic surgeon.

Some Things Change, Some Things Stay the Same: Trends in Canadian Education in Paediatric Cardiology and the Cardiac Sciences

Education in paediatric cardiology has evolved along with clinical care. The availability and application of new technologies in education, in particular, have had a significant impact. Artificial intelligence; virtual, augmented, and mixed reality learning tools; and gamification of learning have all resulted in new opportunities for today's trainees compared with those of the past. A new training model is also being used. Though currently focused on residency education, competency-based medical education is also being applied to undergraduate education in some Canadian medical schools. Competency-based medical education offers a more transparent relationship between education and physicians' social contract with society. It provides greater accountability for programmes and learners to teach and learn the skills required to function as competent specialists. However, it has not come without challenges. Coincident with the application of this model for learners, there has been increased educational accountability for physicians in practice and for the institutions training them. Despite these changes, some things have remained the same. On the positive side, the importance of good clinical teachers to effective learning remains constant. Unfortunately, the mistreatment of learners within our education system also remains and is perhaps the most important challenge facing medical education in Canada today. Learning to be better teachers and learner advocates is an important goal for all of those involved in educating Canadian medical learners.

Is It Time to Create Training Pathways Allowing Earlier Subspecialization within the "House of Orthopaedics"?: AOA Critical Issues

The ability to train an orthopaedic resident in all aspects of orthopaedics in 5 years has become increasingly difficult due to the growth in knowledge and techniques, work-hour restrictions, and reduced resident autonomy. It has become nearly universal for our residents to complete at least 1 subspecialty fellowship prior to entering practice. In some subspecialties, the skills necessary to practice competently have become difficult to master. Simply adding to the current length of training may not address these issues effectively and would add to the economic cost of residency training. Novel training pathways that allow residents to focus earlier and in greater depth on their intended subspecialty while maintaining general orthopaedic competencies can be created without lengthening training. It is time to initiate discussions about these possibilities.

Contemporary Issues in the Acquisition of Orthopaedic Surgical Skills During Residency: Competency-Based Medical Education and Simulation

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Orthopaedic education should produce surgeons who are competent to function independently and can obtain and maintain board certification.

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Contemporary orthopaedic training programs exist within a fixed 5-year time frame, which may not be a perfect match for each trainee.

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Most modern orthopaedic residencies have not yet fully adopted objective, proficiency-based, surgical skill training methods despite nearly 2 decades of evidence supporting the use of this methodology.

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Competency-based medical education backed by surgical simulation rooted in proficiency-based progression has the potential to address surgical skill acquisition challenges in orthopaedic surgery.

American Board of Orthopaedic Surgery’s Initiatives Toward Competency-Based Education

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

The Unintentional Effects on Body Donation Programs of a Competency-Based Curriculum in Postgraduate Medical Education

As medical programs place increasing importance on competency-based training and surgical simulations for residents, anatomy laboratories, and body donation programs find themselves in a position of adapting to changing demands. To better assess the demand for "life-like" cadaveric specimens and evaluate the possible impacts that competency-based medical education could have upon the body donation program of McGill University, Canada, the authors tracked, over the course of the last 10 years, the number of soft-embalmed specimens, along with the number of teaching sessions and the residents enrolled in competency-based programs that are using cadaveric material. The results reveal that the number of soft-embalmed specimens used within residency training increased from 5 in 2009 to 35 in 2019, representing an increase from 6% of bodies to 36.5% of the total number of body donors embalmed in this institution. Correspondingly, the number of annual teaching sessions for residents increased from 19 in 2012 to 116 in 2019. These increases in teaching are correlated with increasing number of residents enrolled in competency-based programs over the last 3 years (Pearson r ranging from 0.9705 to 0.9903, and R² ranging from 0.9418 to 0.9808). Those results suggest that the new skill-centered curricula which require residents to perform specific tasks within realistic settings, exhibit a growing demand for "life-like" cadaveric specimens. Institutions' body donation programs must, therefore, adapt to those greater need for cadaveric specimens, which presents many challenges, ranging from the logistical to the ethical.

Module-Based Arthroscopic Knee Simulator Training Improves Technical Skills in Naive Learners: A Randomized Trial

Purpose

To compare the effectiveness, in comparison to a control group (C), of module-based training (MBT) and traditional learning (TL) as a means of acquiring arthroscopic skills on an arthroscopic surgery simulator.

Methods

Thirty health sciences students with no previous arthroscopy experience were recruited and randomized into 1 of 3 groups: MBT, TL, or C (1:1:1 ratio). Participants in MBT were required to independently practice on a VirtaMed ArthroS simulator (VirtaMed AG, Zurich, Switzerland) for a minimum of 2 hours per week, whereas TL received one-on-one coaching by a senior orthopaedic resident for 15 minutes per week. The control group received no training. All groups were assessed at baseline and at 4 weeks based on objective measures generated by the surgical simulator (procedure time, camera path length, meniscus cutting score, detailed visualization, safety score and total score), and subjective ratings scales (Objective Assessment of Arthroscopic Skill [OAAS] global assessment form, and Competency-Based Assessment form).

Results

Participants in the MBT group trained on average 113 min/week whereas the TL group trained on average 24 min/week. Three-way repeated-measures analysis of variance showed significant group by time interactions for procedure time (P = .006), camera path length (P = .008), safety score (P = .013), total score (P = .003), OAAS form (P < .001), and Competency-Based Assessment form (P < .001). MBT group was superior to C group for procedure time (P = .02), camera path length (P = .003), total score (P = .004), and OAAS form (P = .021), but there were no significant post-hoc differences between MBT and TL groups, or TL and C groups after Bonferroni correction. Total practice time explained 37.5% of the final simulator total score variance.

Conclusions

Knee arthroscopy simulation training with self-learning modules can improve skills in areas such as procedure time, camera path length, and total score in untrained participants compared with a control group.

Clinical Relevance

Module-based simulation training provides additional training time and improves technical skills in naive health science students. It is hoped that this effect can be preserved and applied to junior resident developing in a busy residency program.

Difference in Resident Versus Attending Perspective of Competency and Autonomy During Arthroscopic Rotator Cuff Repairs

A noted deficiency in orthopaedic resident education is a lack of intraoperative autonomy; however, no studies exist evaluating this issue. The purpose of this study was to determine whether there is a difference between resident and attending perception of resident competency and autonomy during arthroscopic rotator cuff repairs and whether increased perceived competency leads to more autonomy.

Development and Implementation of International Curricula for Joint Replacement and Preservation

The number of patients undergoing joint replacement and preservation procedures continues to increase worldwide. Globally, there is no standardized educational pathway, training program, or recognized certification program for surgeons in these procedures. Development and implementation of new competency-based curricula to deliver specific educational events and resources may help trainees and practicing surgeons be able to perform these procedures more effectively and therefore improve patient outcomes in their respective countries. Ideally, a curriculum would be globally standardized and professionally designed to interactively meet the needs of surgeons. A competency-based approach with built-in assessment and evaluation processes is today's educational standard.

Scut to Scholarship: Can Operative Notes be Educationally Useful?

OBJECTIVE

Efforts to implement competency-based medical education require new sources of workplace-based evidence of growth in learning. We used qualitative analysis of operative notes to explore procedural variation in a simple surgical procedure.

DESIGN

We used a grounded theory-based mixed methods approach to depict intersurgeon procedural variation. Our grounded theory approach to analysis included follow up interviews with surgeons and residents to probe their understandings of the reasons for variation in the dictated notes and the current and potential utility of operative notes as a reliable source of data for learning and assessment.

SETTING

Publicly funded tertiary care otolaryngology-head & neck surgery residency program in Ontario, Canada PARTICIPANTS: Using maximum variability sampling, all surgeons performing tonsillectomy in the department (n = 6) contributed operative notes from 65 tonsillectomies, 5 intraoperative observations, and 4 semi-structured interviews. An additional 3 residents from various levels of training contributed semistructured interviews.

RESULTS

Intersurgeon procedural variations persist even in simple surgical procedures such as tonsillectomy. Operative notes appear to capture procedural variations in a limited way. Surgeons and resident make informal educational use of the clerical work of writing and assessing operative notes, but optimization will be required to shift such hidden work into the formal educational domain.

CONCLUSIONS

The implementation of competency-based medical education requires surgical educators to both eliminate low-yield tasks for learning and to find new opportunities for multiple low-stakes assessment. Analysis of operative notes may become a high-yield strategy for learning and assessment if residents and surgeons are coached to use operative notes more reliably and efficiently.

Establishing an Orthopedic Program-Specific, Comprehensive Competency-Based Education Program

BACKGROUND

Competency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation.

MATERIALS AND METHODS

The sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups.

RESULTS

Sixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P < 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P < 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation.

CONCLUSIONS

The CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

Developing and Assessing the Feasibility of Implementing a Surgical Objective Structured Clinical Skills Examination (S-OSCE)

OBJECTIVE

To1 describe the development and evaluate the feasibility of a surgical objective structured clinical examination (OSCE) for the purpose of competency assessment based on the Royal College of Canada's CanMEDS framework.

DESIGN

A unique surgical OSCE was developed to evaluate the clinical and surgical management of common orthopaedic problems using simulated patients and cadaveric specimens. Cases were graded by degree of difficulty (less complex, complex, more complex) Developing an assessment tool with significant resource utilization and good correlation with traditional methods is challenging. The feasibility of an OSCE that evaluates independent clinical and surgical decision making was evaluated. In addition, as part of establishing construct validity, correlation of OSCE scores with previously validated O-scores was performed.

SETTING

A tertiary level academic teaching hospital.

PARTICIPANTS

Thirty-four Postgraduate year 3-5 trainees of a 5-year Canadian orthopedic residency program creating 96 operative case performances available for final review.

RESULTS

The development of the OSCE cases involved a multistep process with attending surgeons, residents and a surgical education consultant. There were 4 different OSCE days, over a 3 year period (2016-2018) encompassing a variety of less complex and more complex procedures. Performance on the OSCE correlated strongly with the (O-SCORE, 0.89) and a linear regression analysis correlated moderately with year of training (r² = 0.5737). The feasibility analysis demonstrated good financial practicality with solid programmatic integration.

CONCLUSIONS

The unique surgical OSCE scores correlate strongly with an established entrustability scale. Administering this OSCE to evaluate preoperative and intraoperative decision making to complement other forms of assessment is feasible. The financial burden to training programs is modest in comparison to the insight gained by both residents and faculty.

Consensus recommendations on balancing educational opportunities and service provision in surgical training: Association of Surgeons in Training Delphi qualitative study

BACKGROUND

Ensuring the highest quality of surgical training remains a challenge as demands on health service provision rise. This study aimed to explore the differences and potential conflicts between service provision and dedicated training activity provided by surgical trainees, and recommend solutions.

METHODS

Participants were drawn from the Association of Surgeons in Training (ASiT) national council. Nominal Group Technique (NGT) was employed by members of the ASiT executive addressing 3 key domains (1) defining differences between training and service tasks, (2) impact of service-provision on training and (3) ways to improve training. A two-round Delphi process was conducted via electronic survey to ASiT council. Consensus was considered achieved for any statement where 80% or more of respondents indicated agreement.

RESULTS

47 statements were generated through NGT which were put to the Delphi process. Consensus was reached on a total of 24/47 statements. Educational or training tasks were identified as being activities which progressed a trainee's skill set, could be tailored to a trainee's own ability, and involved acting as a trainer to more junior colleagues. The negative impact of excess service provision included training quality, trainee mental health, and surgical trainee recruitment. Potential measures to improve training included increasing hospital staffing and resources, protected training times, trainee-specific or competency-based learning and training or incentivising trainers.

CONCLUSION

This trainee-based study provides several consensus recommendations on the characteristics that define surgical training and how a balance between service provision and training can potentially be achieved. Policy makers and health systems may be guided by these to ensure high quality training and a satisfied workforce.

Effect of Teaching Session on Resident Ability to Identify Anatomic Landmarks and Anterior Cruciate Ligament Footprint: A Study Using 3-Dimensional Modeling

Background:

Femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) is an intricate procedure that requires highly specific surgical skills.

Purpose:

To report the ability of residents to identify femoral landmarks and the native ACL footprint before and after a structured formal teaching session as a reflection of overall surgical skill training for orthopaedic surgery residents in Canada.

Study Design:

Controlled laboratory study.

Methods:

A total of 13 senior orthopaedic residents were asked to identify a femoral landmark and an ACL footprint on ten 3-dimensional (3D)–printed knee models before and after a teaching session during the fall of 2018. The 3D models were made based on actual patients with different anatomic morphologic features. ImageJ software was used to quantify the measurements, which were then analyzed through use of descriptive statistics.

Results:

Before and after the teaching session, residents attempted to identify a specific anatomic location (bifurcate and intercondylar ridge intersection) with a mean error per participant ranging from 5.00 to 10.95 mm and 4.79 to 12.13 mm in magnitude, respectively. Furthermore, before and after the teaching session, residents identified the specific position to perform the surgical procedure (ACL femoral footprint), with a mean error per participant ranging from 4.58 to 8.80 mm and 3.87 to 11.07 mm in magnitude, respectively. The teaching session resulted in no significant improvement in identification of either the intersection of the bifurcate and intercondylar ridges (P = .9343 in the proximal-distal axis and P = .8133 in the anteroposterior axis) or the center of the femoral footprint (P = .7761 in the proximal-distal axis and P = .9742 in the anteroposterior axis).

Conclusion:

Although a formal teaching session was combined with a hands-on session that entailed real surgical instrumentation and fresh cadaveric specimens, the intervention seemed to have no direct impact on senior residents’ performance or their ability to demonstrate the material taught. This puts into question the format and efficacy of present teaching methods. Also, it is possible that the 3D spatial perception required to perform these skills is not something that can be taught effectively through a teaching session or at all. Further investigation is required regarding the effectiveness and application of surgical skill laboratories and simulations on the competencies of orthopaedic residents.

Qualitative and quantitative comparison of Thiel and phenol-based soft-embalmed cadavers for surgery training

INTRODUCTION

Surgical skills training has traditionally been limited to formalin embalming that does not provide a realistic model. The aim of this study was to qualitatively and quantitatively compare Thiel and phenol-based soft-embalming techniques: qualitatively in a surgical training setup, and quantitatively by comparing the mechanical and histomorphometric properties of skin specimens embalmed using each method.

MATERIALS AND METHODS

Thirty-four participants were involved in surgical workshops comparing Thiel and phenol-based embalmed bodies. Participants were asked to evaluate the utility of the different models for surgical skills training. In parallel, tensile elasticity evaluation was performed on skin flaps from six fresh-frozen cadavers. Flaps were divided into three groups for each specimen: fresh-frozen, Thiel, and phenol-based embalmed and compared together at 1 month or 1 year after embalming. A histological investigation of the skin structural properties was performed for each embalming type using haematoxylin and eosin and Masson's trichrome.

RESULTS

All participants rated the phenol-based specimens consistently better or equivalent to Thiel for the evaluated parameters. Quantitatively, there were statistically significant differences for the tensile elasticity between the embalming techniques (p < .05). There were no significant differences for the tensile elasticity between phenol-based embalmed skin and fresh state (p = .30), and no significant difference between embalming time was reported (p = .47). Histologically, the integrity of the skin was better preserved with the phenol-based technique.

CONCLUSION

Phenol-based embalming provides as realistic or better of a model as Thiel embalming for surgical training skills and was generally preferred over Thiel model. The phenol-based embalming better preserved the integrity of the skin.

Resident Independence Performing Common Orthopaedic Procedures at the End of Training: Perspective of the Graduated Resident

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) has established minimum exposure rates for specific orthopaedic procedures during residency but has not established the achievement of competence at the end of training. The determination of independence performing surgical procedures remains undefined and may depend on the perspective of the observer. The purpose of this study was to understand the perceptions of recently graduated orthopaedic residents on the number of cases needed to achieve independence and on the ability to perform common orthopaedic procedures at the end of training.

METHODS

We conducted a web survey of all 727 recently graduated U.S. orthopaedic residents sitting for the 2018 American Board of Orthopaedic Surgery Part I Examination in July 2018. The surveyed participants were asked to assess the ability to independently perform 26 common adult and pediatric orthopaedic procedures as well as to recommend the number of cases to achieve independence at the end of training. We compared these data to the ACGME Minimum Numbers and the average ACGME resident experience data for residents who graduated from 2010 to 2012.

RESULTS

For 14 (78%) of the 18 adult procedures, >80% of respondents reported the ability to perform independently, and for 7 (88%) of the 8 pediatric procedures, >90% reported the ability to perform independently. The resident-recommended number of cases for independence was greater than the ACGME Minimum Numbers for all but 1 adult procedure. For 18 of the 26 adult and pediatric procedures, the mean 2010 to 2012 graduated resident exposure was significantly less than the mean number recommended for independence by 2018 graduates (p < 0.05).

CONCLUSIONS

Overall, recently graduated residents reported high self-perceived independence in performing the majority of the common adult and pediatric orthopaedic surgical procedures included in this study. In general, recently graduated residents recommended a greater number of case exposures to achieve independence than the ACGME Minimum Numbers.

A Timely Problem: Parental Leave During Medical Training

Shifting demographics and concerns about burnout prevention merit a reexamination of existing structures and policies related to leaves of absence that may be necessary during medical training. In this Invited Commentary, the authors address the issue of parental leave for medical students and residents. Discussion about parental leave for these trainees is not new. Despite decades of dialogue, leave policies throughout the undergraduate and graduate medical education continuum lack standardization and are currently ill defined and inadequate. There are a number of barriers to implementation. These include stigma, financial concerns, workforce and duty hours challenges, and the historically rigid timeline for progression from one stage of medical training to the next. Potential solutions include parent-friendly curricular innovations, competency-based medical education, and provision of short-term disability insurance. Most important, adopting more flexible approaches to graduation requirements and specialty board examination eligibility must be addressed at the national level. The authors identify cultural and practical challenges to standardizing parental leave options across the medical education continuum and issue a call to action for implementing potential solutions.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents' performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.

METHODS

Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.

RESULTS

There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).

CONCLUSIONS

VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum.

LEVEL OF EVIDENCE

Level 1.

Global variability in orthopedic surgery training

Medical and orthopedic training varies throughout the world. The pathways to achieve competency in orthopedic surgery in other countries differ greatly from those in the United States. This review summarizes international educational requirements and training pathways involved in the educational development of orthopedic surgeons. Understanding the differences in training around the world offers comparative opportunities which may lead to the improvement in education, training, and competency of individuals providing orthopedic care.

Subspecialty Rotation Exposure Across Accreditation Council for Graduate Medical Education-Accredited Orthopaedic Surgery Residency Programs

Introduction:

The Accreditation Council for Graduate Medical Education (ACGME) mandates certain procedural minimums for graduating residents of orthopaedic surgery programs and provides residency programs with comparative data on surgical case volume. It provides much less guidance and feedback to programs regarding the amount of time residents should spend on different rotations during residency. Comparative data regarding how much time residents are spending on general and subspecialty rotations may be of use to educational leadership as they consider curriculum changes and alternative training structures. The purpose of this study is to summarize the subspecialty rotation exposure across ACGME-accredited orthopaedic residency programs and to correlate the subspecialty rotation exposure with available program-specific factors.

Methods:

This study contacted 162 ACGME-accredited orthopaedic residency programs and received rotation schedules from 115 programs (70.1%). Rotation schedules for postgraduate year 2 to 5 residents were categorized into the number of months spent on the following rotations: general orthopaedics, trauma, pediatrics, hand, sport, foot and ankle, arthroplasty, oncology, spine, research, and elective. The percentage of residency spent in each category was then calculated as the number of months divided by 48 months. Differences in the percent of residency spent on subspecialty rotations were compared for the following variables: program size and presence of subspecialty fellowships at the institution.

Results:

On average, the greatest percentage of residency spent was in the following categories: trauma (16.6%; 8.0 months), general orthopaedics (13.7%; 6.6 months), and pediatrics (12.5%; 6.0 months). Rotations with the highest variation between programs included the following: general orthopaedics (SD 5.8 months; range 0 to 30 months), sport (SD 2.5 months; range 0 to 15 months), and arthroplasty (SD 2.3 months; range 0 to 11.8 months). Sixty-seven programs (63.2%) had dedicated blocks for research, and 25 programs (23.6%) had dedicated blocks for electives. No notable correlations were found between subspecialty exposure and program size or availability of subspecialty fellowship training at the program.

Conclusion:

Variability exists between ACGME-accredited orthopaedic surgery residency programs in subspecialty rotation exposure. Summarizing the subspecialty rotation exposure across accredited orthopaedic residency programs is useful to graduate medical education leadership for comparative purposes because they design and modify resident curricula.

An Extensible Orthopaedic Wire Navigation Simulation Platform

The demand for simulation-based skills training in orthopaedics is steadily growing. Wire navigation, or the ability to use 2D images to place an implant through a specified path in bone, is an area of training that has been difficult to simulate given its reliance on radiation based fluoroscopy. Our group previously presented on the development of a wire navigation simulator for a hip fracture module. In this paper, we present a new methodology for extending the simulator to other surgical applications of wire navigation. As an example, this paper focuses on the development of an iliosacral wire navigation simulator. We define three criteria that must be met to adapt the underlying technology to new areas of wire navigation; surgical working volume, system precision, and tactile feedback. The hypothesis being that techniques which fall within the surgical working volume of the simulator, demand a precision less than or equal to what the simulator can provide, and that require the tactile feedback offered through simulated bone can be adopted into the wire navigation module and accepted as a valid simulator for the surgeons using it. Using these design parameters, the simulator was successfully configured to simulate the task of drilling a wire for an iliosacral screw. Residents at the University of Iowa successfully used this new module with minimal technical errors during use.

Perceptions of competency-based medical education from medical student discussion forums

BACKGROUND

Competency-based medical education (CBME) is becoming widely implemented in medical education. Trainees' perceptions of CBME are important factors in the implementation and acceptance of CBME. Online discussion groups allow unique insight into trainees' perceptions of CBME during residency training.

METHODS

We analysed 867 posts from 20 discussion threads in Premed 101 (Canadian) and 2756 posts from 50 threads in Student Doctor Network (SDN) (American) using NVivo 11. Inductive content analysis was used to develop a data-driven coding scheme that evolved throughout the analysis. Measures were taken to ensure the trustworthiness of findings, including co-coding of a subsample of 600 posts, peer debriefing, consensus-based analytical decision making and the maintenance of an audit trial.

RESULTS

Medical residents and students participating in the discussion forums emphasised select themes regarding the implementation of CBME in residency training. Concerns about CBME in Canada primarily involved its implications for the length of residency and post-residency opportunities. Posts on the American forum had a prominent focus on differing areas, such as the subjectivity in the assessment of core competencies and the role of CBME in termination of a resident's position.

CONCLUSIONS

Online discussion groups have the potential to provide unique insight into perceptions of CBME. The presented concerns may have implications for refining the model of CBME and illustrate the importance of providing clarification for trainees regarding length of training and evaluation structures from those involved in designing of CBME programmes.

Comparison of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) to a Single-Item Performance Score

Construct: We compared a single-item performance score with the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) for their ability in assessing surgical competency.

BACKGROUND

Surgical programs are adopting competency-based frameworks. The adoption of these frameworks for assessment requires tools that produce accurate and valid assessments of knowledge and technical performance. An assessment tool that is quick to complete could improve feasibility, reduce delays, and result in a higher volume of assessments of learners. Previous work demonstrated that the 9-item O-SCORE can produce valid results; the goal of this study was to determine if a single-item performance rating (Is candidate competent to independently complete procedure: yes or no) completed at a separate viewing would correlate to the O-SCORE, thus increasing feasibility of procedural competence assessment.

APPROACH

Nineteen residents and 2 staff orthopedic surgeons from the University of Ottawa volunteered for a 2-part OSCE-style station including a written questionnaire and videotaped simulated open reduction and internal fixation midshaft radius fracture. Each performance was rated independently by 3 orthopedic surgeons using a single-item performance score (Time 1). The performances were assessed again 6 weeks later by the 3 raters using the O-SCORE (Time 2). Correlation between the single-item performance score and the O-SCORE were evaluated.

RESULTS

Three orthopedic surgeons completed 21 ratings each resulting in 63 orthopedic ratings. There was a high level of correlation and agreement between the single-item performance score at Time 1 and Time 2 (κ correlation =0.72-1.00; p < .001; percentage agreement =90%-100%). The reliability of the O-SCORE at Time 2 with three raters was 0.83 and the internal consistency was 0.89. There was a tendency for each rater to assign more yes responses to the more senior trainees.

CONCLUSIONS

A single-item performance score correlated highly with the O-SCORE in an orthopedic setting. A single-item score could be used to supplement a multi-item score with similar results in orthopedics. There is still benefit in completing multi-item scores such as the O-SCORE evaluations to guide specific areas of improvement and direct feedback.

Achieving Microsurgical Competency in Orthopaedic Residents Utilizing a Self-Directed Microvascular Training Curriculum

BACKGROUND

Education in microvascular surgery is limited by variable experience, a difficult learning curve, and potentially catastrophic complications caused by failed anastomoses. Furthermore, utilization of live-animal training models can be difficult because of lack of access and high maintenance costs. The purpose of this study was to determine the effectiveness and cost of a self-directed microvascular training curriculum utilizing synthetic microvessels and nonliving models in an orthopaedic residency program.

METHODS

Twenty-five orthopaedic residents ranging from postgraduate year (PGY)-1 to PGY-4 were prospectively enrolled. The curriculum consisted of learning the basics of microsurgery on nonliving models and progressed to anastomoses on a 1-mm synthetic microvessel. Outcomes included Global Rating Scale (GRS) scores (5 to 25 points), patency, anastomosis time, comfort level (1 to 10 points), time to complete the curriculum, and curriculum utility (1 to 10 points). Blinded qualitative assessments (from 1 to 10 points) of pre-curriculum and post-curriculum anastomoses were made by 4 hand surgery faculty members. Outcome measures were obtained at baseline and post-curriculum. The curriculum cost was calculated as the setup cost and the maintenance cost per resident. Student t tests and Fisher exact tests were utilized for significance.

RESULTS

All residents successfully completed the curriculum. The mean anastomosis time (and standard deviation) decreased from 40 ± 3 minutes to 22 ± 4 minutes (p < 0.001). The mean GRS score improved from 12 ± 2 points to 18 ± 2 points (p < 0.01). Patency was achieved by 44% at baseline evaluation and by 96% at post-curriculum evaluation (p < 0.0001). The mean comfort level improved from 3 ± 1.2 points to 6 ± 1.7 points (p < 0.0001) on a scale of 1 to 10 points. Also on a scale of 1 to 10, the blinded mean qualitative anastomoses score improved from 4.8 ± 2.2 points (poor) to 8.0 ± 1.1 points (good) (p < 0.0001). The mean time to complete the curriculum was 5.5 ± 1.4 hours, and, on a scale of 1 to 10, curriculum utility was rated by the residents to be 8 ± 1.8 points. The cost of the initial setup was $1,795 with a yearly utilization cost per resident of $42.

CONCLUSIONS

The implementation of a self-directed curriculum utilizing synthetic microvessels and nonliving models demonstrated significant improvements in resident microvascular skill. This curriculum represents a modest startup cost and low yearly cost per resident.

Association of a Competency-Based Assessment System With Identification of and Support for Medical Residents in Difficulty

IMPORTANCE

Competency-based medical education is now established in health professions training. However, critics stress that there is a lack of published outcomes for competency-based medical education or competency-based assessment tools.

OBJECTIVE

To determine whether competency-based assessment is associated with better identification of and support for residents in difficulty.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of secondary data from archived files on 458 family medicine residents (2006-2008 and 2010-2016) was conducted between July 5, 2016, and March 2, 2018, using a large, urban family medicine residency program in Canada.

EXPOSURES

Introduction of the Competency-Based Achievement System (CBAS).

MAIN OUTCOMES AND MEASURES

Proportion of residents (1) with at least 1 performance or professionalism flag, (2) receiving flags on multiple distinct rotations, (3) classified as in difficulty, and (4) with flags addressed by the residency program.

RESULTS

Files from 458 residents were reviewed (pre-CBAS: n = 163; 81 [49.7%] women; 90 [55.2%] aged >30 years; 105 [64.4%] Canadian medical graduates; post-CBAS: n = 295; 144 [48.8%] women; 128 [43.4%] aged >30 years; 243 [82.4%] Canadian medical graduates). A significant reduction in the proportion of residents receiving at least 1 flag during training after CBAS implementation was observed (0.38; 95% CI, 0.377-0.383), as well as a significant decrease in the numbers of distinct rotations during which residents received flags on summative assessments (0.24; 95% CI, 0.237-0.243). There was a decrease in the number of residents in difficulty after CBAS (from 0.13 [95% CI, 0.128-0.132] to 0.17 [95% CI, 0.168-0.172]) depending on the strictness of criteria defining a resident in difficulty. Furthermore, there was a significant increase in narrative documentation that a flag was discussed with the resident between the pre-CBAS and post-CBAS conditions (0.18; 95% CI, 0.178-0.183).

CONCLUSIONS AND RELEVANCE

The CBAS approach to assessment appeared to be associated with better identification of residents in difficulty, facilitating the program's ability to address learners' deficiencies in competence. After implementation of CBAS, residents experiencing challenges were better supported and their deficiencies did not recur on later rotations. A key argument for shifting to competency-based medical education is to change assessment approaches; these findings suggest that competency-based assessment may be useful.

What They May Not Tell You and You May Not Know to Ask: What is Expected of Surgeons in Their First Year of Independent Practice

OBJECTIVE

The objective of this study was to explore the views and expectations that practicing general surgeons have of their junior colleagues who have recently finished training.

DESIGN

This is a qualitative study performed using focus group data consisting of open-ended questions concentrating on essential qualities and attributes of surgeons, behaviors observed in newly-graduated surgeons, and appropriate oversight of junior partners. Qualitative analysis was performed using grounded theory methodology with transcripts coded by 3 independent reviewers.

SETTING

Focus groups were conducted with surgeons practicing in rural and urban community settings.

PARTICIPANTS

Focus groups consisted of practicing general surgeons throughout the state of Oregon.

RESULTS

Focus groups were comprised of 31 practicing surgeons (10 female, 21 male) with varying ages and levels of experience practicing in both rural and urban environments. Qualitative analysis revealed the need for surgeons with strong interpersonal skills, teamwork, judgment, and broad technical skills who possess the appropriate amount of confidence and know when to ask for help. Frequently noted themes identified, included not knowing when to ask for help, overconfidence or underconfidence, as well as lack of judgment and lack of either quality or breadth of technical skill. Current oversight included direct observation, subjective evaluations from staff and colleagues, analysis of outcomes/quality, and either formal or informal mentorship arrangements.

CONCLUSIONS

This study highlights the need for graduating surgeons to be competent in multiple domains. The importance of knowing when to ask for help was stressed by practicing surgeons in both the rural and urban community setting, but is underemphasized in residency training, possibly due to less indirect resident supervision. Surgeons also emphasized the importance of mentorship, as professional growth continues long after completion of training.

Eight-year outcomes of a competency-based residency training program in orthopedic surgery

Background: The Division of Orthopaedic Surgery at the University of Toronto implemented a pilot residency training program that used a competency-based framework in July of 2009. The competency-based curriculum (CBC) deployed an innovative, modularized approach that dramatically intensified both the structured learning elements and the assessment processes. Methods: This paper discusses the initial curriculum design of the CBC pilot program; the refinement of the curriculum using curriculum mapping that allowed for efficiencies in educational delivery; details of evaluating resident competence; feedback from external reviews by accrediting bodies; and trainee and program outcomes for the first eight years of the program's implementation. Results: Feedback from the residents, the faculty, and the postgraduate residency training accreditation bodies on the CBC has been positive and suggests that the essential framework of the program may provide a valuable tool to other programs that are contemplating embarking on transition to competency-based education. Conclusions: While the goal of the program was not to shorten training per se, efficiencies gained through a modular, competency-based program have resulted in shortened time to completion of residency training for some learners.

Ten key features of the future medical school-not an impossible dream

Significant developments in medical education are necessary if medical schools are to respond to the pressures from advances in medicine, changes in health care delivery, and patient and public expectations. This article describes 10 key features of the medical school of the future: the move from the ivory tower to the real world, from just-in-case learning to just-in-time learning, from the basic science clinical divide to full integration, from undervalued teaching and the teacher to recognition of their importance, from the student as a client to the student as partner, from a mystery tour to a mapped journey, from standard uniform practice to an adaptive curriculum, from a failure to exploit learning technology to its effective and creative use, from assessment of learning to assessment for learning, and from working in isolation to greater collaboration. A move in the directions specified is necessary and possible. With some of the changes proposed already happening, it is not an impossible dream.

Progressive Autonomy in the Era of Increased Supervision: AOA Critical Issues

The observation of decreased resident autonomy, ultimately influencing the readiness of a new graduate to practice, has been supported with a number of recent surveys. This perceived lack of autonomy is felt to be due, in part, to many reasons, including duty-hour regulations, increased supervision requirements, patient safety measures, concern for complication rates, and other performance measures. Pressure on faculty members to have increased clinical productivity may not allow for more resident autonomy.Increased clinical exposure to improve resident independence may come from several suggested areas. First, restructuring the residency program to allow for more clinical time may be one way to improve education. Second, increased use of surgical simulation will allow for more experience to develop technical skills within a controlled environment. Surgical simulators can be used to acquire new skills and also as a means of assessing competence. Third, competency-based education (CBE) has been offered as a way to improve resident education. At its core, CBE offers criterion-based assessments for residents and faculty that allow for more frequent feedback.

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program

Background

The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.

Methods

The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.

Results

Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4–71.0%, p < 0.01) and palate (50.6–66.0%, p < 0.01). General technical competency scores also improved (63.6–72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).

Conclusion

Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.

Education in Pediatrics Across the Continuum (EPAC): First Steps Toward Realizing the Dream of Competency-Based Education

The Education in Pediatrics Across the Continuum (EPAC) Study Group is developing the first competency-based, time-variable progression from undergraduate medical education (UME) to graduate medical education (GME) in the history of medical education in the United States. EPAC, an innovation project sponsored by the Association of American Medical Colleges and supported by the Josiah Macy Jr. Foundation, was developed through a collaboration between five medical schools and multiple professional organizations with an interest in undergraduate and graduate medical education. The planning and implementation process demanded cooperatively addressing practical barriers such as education requirements for licensure and developing approaches to learner assessment that provided meaningful information about competency. Each participating school now has at least three cohorts of learners participating, and the program is transitioning its first cohort of students from UME to GME based on achievement of predetermined competencies that allow this transition. Members of the first cohort of learners in this program have begun their pediatric residency training at different times beginning in late 2016, confirming the feasibility of competency-based advancement from UME to GME in pediatrics. Although there is still much to learn about the outcomes of EPAC learners' professional development in residency training and beyond, EPAC has defined an operational approach to a different path through medical school and into residency training, based on the attainment of competence.

Nonspecialist Raters Can Provide Reliable Assessments of Procedural Skills

BACKGROUND

Competency-based learning has become a crucial component in medical education. Despite the advantages of competency-based learning, there are still challenges that need to be addressed. Currently, the common perception is that specialist assessment is needed for evaluating procedural skills which is difficult owing to the limited availability of faculty time. The aim of this study was to explore the validity of assessments of video recorded procedures performed by nonspecialist raters.

METHODS

This study was a blinded observational trial. Twenty-three novices (senior medical students) and 9 experienced doctors were video recorded while each performing 2 flexible cystoscopies on patients. The recordings were anonymized and placed in random order and then rated by 2 experienced cystoscopists (specialist raters) and 2 medical students (nonspecialist raters). Flexible cystoscopy was chosen as it is a simple procedural skill that is crucial to master in a resident urology program.

RESULTS

The internal consistency of assessments was high, Cronbach's α = 0.93 and 0.95 for nonspecialist and specialist raters, respectively (p < 0.001 for both correlations). The interrater reliability was significant (p < 0.001) with a Pearson's correlation of 0.77 for the nonspecialists and 0.75 for the specialists. The test-retest reliability showed the biggest difference between the 2 groups, 0.59 and 0.38 for the nonspecialist raters and the specialist raters, respectively (p < 0.001).

CONCLUSION

Our study suggests that nonspecialist raters can provide reliable and valid assessments of video recorded cystoscopies. This could make mastery learning and competency-based education more feasible.

A Lack of Continuity in Education, Training, and Practice Violates the "Do No Harm" Principle

The paradigm shift to competency-based medical education (CBME) is under way, but incomplete implementation is blunting the potential impact on learning and patient outcomes. The fundamental principles of CBME call for standardizing outcomes addressing population health needs, then allowing time-variable progression to achieving them. Operationalizing CBME principles requires continuity within and across phases of the education, training, and practice continuum. However, the piecemeal origin of the phases of the "continuum" has resulted in a sequence of undergraduate to graduate medical education to practice that may be continuous temporally but bears none of the integration of a true continuum.With these timed interruptions during phase transitions, learning is not reinforced because of a failure to integrate experiences. Brief block rotations for learners and ever-shorter supervisory assignments for faculty preclude the development of relationships. Without these relationships, feedback falls on deaf ears. Block rotations also disrupt learners' relationships with patients. The harms resulting from such a system include decreases in patient satisfaction with their care and learner satisfaction with their work. Learners in this block system also demonstrate an erosion of empathy compared with those in innovative longitudinal training models. In addition, higher patient mortality during intern transitions has been demonstrated.The current medical education system is violating the first principle of medicine: "Do no harm." Full implementation of competency-based, time-variable education and training, with fixed outcomes aligned with population health needs, continuity in learning and relationships, and support from a developmental program of assessment, holds great potential to stop this harm.

"Taking Training to the Next Level": The American College of Surgeons Committee on Residency Training Survey

OBJECTIVE

The American College of Surgeons (ACS) appointed a committee of leaders from the ACS, Association of Program Directors in Surgery, Accreditation Council for Graduate Medical Education, and American Board of Surgery to define key challenges facing surgery resident training programs and to explore solutions. The committee wanted to solicit the perspectives of surgery resident program directors (PDs) given their pivotal role in residency training.

DESIGN

Two surveys were developed, pilot tested, and administered to PDs following Institutional Review Board approval. PDs from 247 Accreditation Council for Graduate Medical Education-accredited general surgery programs were randomized to receive 1 of the 2 surveys. Bias analyses were conducted, and adjusted Pearson χ² tests were used to test for differences in response patterns by program type and size.

SETTING

All accredited general surgery programs in the United States were included in the sampling frame of the survey; 10 programs with initial or withdrawn accreditation were excluded from the sampling frame.

PARTICIPANTS

A total of 135 PDs responded, resulting in a 54.7% response rate (Survey A: n = 67 and Survey B: n = 68). The respondent sample was determined to be representative of program type and size.

RESULTS

Nearly 52% of PD responses were from university-based programs, and 41% had over 6 residents per graduating cohort. More than 61% of PDs reported that, compared to 10 years ago, both entering and graduating residents are less prepared in technical skills. PDs expressed significant concerns regarding the effect of duty-hour restrictions on the overall preparation of graduating residents (61%) and quality of patient care (57%). The current 5-year training structure was viewed as needing a significant or extensive increase in opportunities for resident autonomy (63%), and the greatest barriers to resident autonomy were viewed to be patient preferences not to be cared for by residents (68%), liability concerns (68%), and Centers for Medicare and Medicaid Services regulations (65%). Although 64% of PDs believe that moderate or significant changes are needed in the current structure of residency training, 35% believe that no changes in the structure are needed. When asked for their 1 best recommendation regarding the structure of surgical residency, only 22% of PDs selected retaining the current 5-year structure. The greatest percentage of PDs (28%) selected the "4 + 2" model as their 1 best recommendation for the structure to be used. In the area of faculty development, 56% of PDs supported a significant or extensive increase in Train the Teacher programs, and 41% supported a significant or extensive increase in faculty certification in education.

CONCLUSIONS

Information regarding the valuable perspectives of PDs gathered through these surveys should help in implementing important changes in residency training and faculty development. These efforts will need to be pursued collaboratively with involvement of key stakeholders, including the organizations represented on this ACS committee.

Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health

To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.

Can We Agree on Expectations and Assessments of Graduating Residents?: 2016 AOA Critical Issues Symposium

Orthopaedic educators are responsible for training a prepared and competent workforce that will provide effective care for a growing number of patients with musculoskeletal conditions. Currently, there are both internal and external forces that pose substantial challenges to medical students, residents, program directors, faculty members, and chairs in achieving this goal. One area of particular concern is the education of surgeons, whose knowledge and professional behavior must be matched by their ability to acquire procedural skills. In order to address this issue, many training systems have implemented a competency-based training approach into their curricula. This article discusses the efforts that orthopaedic training bodies in Canada and Australia have taken toward competency-based education and what steps the American Board of Orthopaedic Surgery (ABOS), the Council of Orthopaedic Residency Directors (CORD), the American Orthopaedic Association (AOA), the American Academy of Orthopaedic Surgeons (AAOS), and the Accreditation Council for Graduate Medical Education (ACGME) are considering to improve residency education in the current and future environments.

Changing the culture of medical training: An important step toward the implementation of competency-based medical education

OBJECTIVE

The current medical education system is steeped in tradition and has been shaped by many long-held beliefs and convictions about the essential components of training. The objective of this article is to propose initiatives to overcome biases against competency-based medical education (CBME) in the culture of medical education.

MATERIALS AND METHODS

At a retreat of the International Competency Based Medical Education (ICBME) Collaborators group, an intensive brainstorming session was held to determine potential barriers to adoption of CBME in the culture of medical education. This was supplemented with a review of the literature on the topic.

RESULTS

There continues to exist significant key barriers to the widespread adoption of CBME. Change in educational culture must be embraced by all components of the medical education hierarchy. Research is essential to provide convincing evidence of the benefit of CBME.

CONCLUSIONS

The widespread adoption of CBME will require a change in the professional, institutional, and organizational culture surrounding the training of medical professionals.