A look to the future: Teaching the next generation of orthopedic surgeons
Orthopedic residency programs are currently producing a group of orthopedic surgeons unlike any other. Today’s residents rely less on the traditional textbook and more on technology, they learn more surgical skills through simulation and they work within strict work-hour restrictions — all of which have affected residency program curricula and teaching styles.
Work-hour restrictions have forced residency programs to become more efficient, and teaching styles have been adjusted to meet the learning styles of today’s residents.
“You cannot run a residency program the way you did 10 years ago, but do it in 80 hours per week,” William N. Levine, MD, Frank E. Stinchfield Professor and Chairman of Clinical Orthopedic Surgery at New York Presbyterian/Columbia University Medical Center, told Orthopedics Today. “Residency program directors, department chairs and faculty have to become much more efficient in the way they educate. Every hour should be valued as a critical hour in the resident’s week, and if it is not serving a strict educational purpose, then you need to do things differently.”
“The ‘next generation of orthopedic surgeons’ is an exceptionally talented group when you look at their academic credentials,” Thomas Kuivila, MD,vice chairman for education and residency program director in the Department of Orthopedic Surgery at the Cleveland Clinic, told Orthopedics Today. “The Part I U.S. Medical Licensing Examination scores are through the roof. A lot of these people have also participated in some fairly substantial research, so they are coming in with a good sense of what constitutes good research.”
Image: Columbia Orthopedics
Changes in teaching style
Current orthopedic trainees are similar to previous generations in terms of learning and retaining material, according to Kuivila. “The way we teach is not dramatically different in terms of presenting material and trying to assess how they have grasped the material,” he said. “I do not think millennials have a different attention span, but our teaching style has changed to one to which this current generation is accustomed in terms of how they are able to access reference material.”
Today’s trainees are more “tech-savvy” than those in previous years, according to Ann E. Van Heest, MD, professor and vice chair of education in the Department of Orthopaedic Surgery at University of Minnesota. “They have a low dependence on traditional textbooks and paper copies of journals and articles, and they have a significantly higher reliance on PubMed and electronic access for textbooks and articles.”
Educators have adjusted their teaching style to incorporate millennials’ different learning style, but also because of a better understanding of how adults learn, according to Levine. Rather than the typical PowerPoint lecture, Levine’s lectures involve interactive question-and-answer discussions and case examples. “Every single person in the lecture is involved because they have to be,” he said. “These types of lectures compel the residents to be as prepared as they can be for the lecture because they are going to be asked questions. There is a different level of preparation, a different level of engagement and therefore a different level of retention of knowledge.”
For faculty, however, this teaching style is often more difficult. “You have to have a blueprint in your mind, a roadmap of how you are going to progress through the topic,” Levine said.
At Levine’s institution, it is now mandatory for all faculty members to complete an effective educators course. “When you take this course, one of the first things you learn is that for adults — especially this generation of trainees — the worst medium for learning is the classical classroom didactic PowerPoint presentation,” he said.
Orthopedic faculty members also utilize much of this new technology in their lectures and provide orthopedic trainees with a broad range of electronic media for teaching materials. For example, “We are able to bank all of the lectures so that trainees can look at them if they miss a lecture,” Kuivila said. “They can go through the lecture slides because they are all archived.”
In addition, at the Cleveland Clinic, all trainees have subscriptions to OrthoBullets, which is a test bank that prepares orthopedic trainees for standardized exams. “That is a huge advance in terms of studying,” Kuivila said. “We used to have a significant resident library with lots of journals and textbooks, and we have cut back dramatically on the amount of hard-copy books and journals because so much is available online and/or via web subscription.”
In addition to technological advances, the current generation is also affected by worldwide and national issues that have not affected previous generations, such as terrorism, international crises, health care and the demands of the Affordable Care Act, Lisa K. Cannada, MD, associate professor in the Department of Orthopaedic Surgery at Saint Louis University, told Orthopedics Today. “Trainees have to be a little more in tune with how not being involved in professional organizations can affect your practice and your ability to practice,” she said. “We have to teach them about social issues so that they are well aware of how health insurance and how not getting involved will affect their care and their future as a physician.”
Cannada also added that faculty members need to consider social media, which are a large part of trainees’ lives, when teaching them. “We have to realize that they learn differently than we do, and we have to develop teaching methods that work on computers or on an app and develop e-books instead of good old-fashioned textbooks,” she said.
Faculty are also trying to find the optimal way to educate residents with a fewer number of work hours. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated that duty hours of trainees be limited to an 80-hour work week. The ACGME placed additional restrictions on work hours in 2011 when it mandated that postgraduate year (PGY)-1 residents cannot work more than 16 hours consecutively and cannot work overnight.
Ann E. Van Heest
“The advantages of work-hour restrictions are better work–life balance for residents, which I think is important,” Van Heest said. “Disadvantages have been decreased clinical contact time with an increased amount of knowledge that they need to learn. Ninety percent of residents now do fellowships, and that is thought to be because it is difficult to go into practice without an additional year of training.”
Kuivila added that the work-hour restrictions also teach efficiency.
“People realize they have a prescribed amount of time to get some of their work done relative to ward work and chart work,” he said.
In addition, the work-hour restrictions have boosted morale because they dictate that residents have time off, specifically 1 day off every 7 days, which Kuivila said is important for mental health.
Levine and Spang recently conducted a study reviewing the literature on the effects of the 2003 and 2011 rules and conducted a national survey of residents and residency directors regarding their opinions of the newer work-hour restrictions.
“Those  rule changes were universally disliked by residency directors and residents,” Levine said. “The concern was that PGY-1 residents were often put into situations and into hospital environments that were some of the most high-risk with some of the least amount of supervision, mainly the intensive care units. Rather than figure out a mandate that they need to be supervised better — which is certainly true — the ACGME eliminated that possibility by not letting PGY-1 residents stay overnight in the hospital. It has created a significant issue with PGY-1 residents who are now coming into their second year of residency much less well prepared and more questionably trained than in previous years.”
Levine and Spang found that 19.7% of those surveyed were satisfied with the 2011 regulations; 58.9% believed that the 80-hour work week is appropriate.
“Surgeons cannot learn their craft in simulators or online,” Levine said. “Surgery happens at off hours, emergencies happen at off hours, and you need to be in the operating room to be skilled in what you do.”
Levine believes the 80-hour work week limit should be reconsidered for surgical specialties. “It is not to say that we should go back to the old style of a crazy number of work hours, but mandating all specialties to an 80-hour work week had an unintended downstream consequence,” he said. “The ACGME did not take into consideration that surgical subspecialties ought to be viewed with a different prism and perhaps there should have been a better accommodation for them.”
According to Cannada, the work-hour restrictions have not led to higher scores on examinations, which was one of the original intentions. For example, in 2009, Froelich and his colleagues evaluated data from the ACGME national database for 3 academic years before and 5 years after the 2003 changes. They found no statistically significant changes in the orthopedic in-training examination scores, but did see an increase in the total number of cases performed after the 2003 restrictions were implemented. According to a 2013 narrative review by Fabricant and colleagues, the rate of failure on the American Board of Orthopaedic Surgeons (ABOS) board-certification examinations increased from 13% in 2006 to 19% in 2010.
“When the work-hour restrictions went into place, we thought people would have more time to study and that we would see a rise in training scores and a bump in the overall scores on the ABOS examination,” Kuivila said. “The board found that when the 80-hour work week went into effect, board scores dipped a little bit and stayed on a downward trend for about 5 years and then leveled out.”
“A PGY-1 resident never gets to spend a night in the hospital their whole first year, and oftentimes, I feel you learn best in the middle of the night when there are crises,” Cannada said. “In their second year, they have less experience to refer to in order to help them make crucial decisions and to address critical issues with patients.”
Cannada explained that the work-hour restrictions are eliminating important learning experiences for residents. “What they pick up on, what they learn will address complex issues in the future,” she said. “For that reason, we all know that most of the residents are doing fellowships, some are even doing two fellowships because of the perhaps decreased exposure to cases and critical issues to help with decision making.”
Work-hour restrictions have also reduced the continuity of care that residents once had with patients, according toOrrin I. Franko, MD, chief resident in the Orthopedic Surgery Resident Training Program at University of California, San Diego. “A positive treatment experience could be fragmented,” he said. “Residents do not get the experience of following a patient from admission through treatment. Although work-hour restrictions might be better for mental health at certain times, residents do not often have the connection or satisfaction of taking ownership in truly caring for their patient, which is harmful both for education and general well-being.”
Phillip N. Williams, MD, chief resident at Hospital for Special Surgery in New York, echoed Franko’s concerns. “As the older residents, I would say we have noticed with the work-hour restrictions that there is a move toward almost shift-type work for residents,” he said. “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.”
Working fewer hours during residency also prevents trainees from learning how to properly balance work–life issues, which can lead to burnout in the future, according to Cannada. Orthopedic residency programs have put several precautions in place to help residents avoid and deal with burnout.
Orrin I. Franko
“Burnout is largely personality-driven,” Kuivila said. “Some people can work hard and not get burned out, while some people can work even less and get burned out. It is a matter of leaving certain things at work so you are not constantly worrying about work issues, such as when you have a patient who is not doing well.”
Franko suggested that support from coresidents and program directors can help avoid and alleviate burnout. “Burnout has a lot to do with the culture of the program and the support a resident feels like he or she is getting,” he said. “As a chief resident, I always try to check in with my junior residents to make sure they are having time to take for themselves, to be with their families because they need those opportunities, even just to get a good night’s sleep or to refresh.”
One intention of the work-hour restrictions was to decrease the amount of time residents spend in service and increase the amount of time spent on educational activities, according to Van Heest. “Part of those educational activities is trying to get a structured curriculum and trying to teach a certain amount of surgical skills prior to even getting residents in the operating room,” she said.
To meet these goals, the ABOS now requires residents to complete surgical simulation training during PGY-1 when they have less clinical time because of the reduced hours. Several programs in the United States are now working on curriculum designs that incorporate surgical simulation and teach and test surgical skills in the first year. They also need to have a dedicated simulation space, according to Van Heest.
“There are some dramatic benefits to doing simulated skills in the lab,” Kuivila said. “Some procedures have a steep learning curve, so it takes a number of repetitions before trainees have the manual dexterity to do it right. Simulators allow trainees to practice over and over again without any harm to the patient. They may have some results that are less than optimal if they do not have good skills when performing the procedure on a patient.”
Kuivila added that simulation is not a substitute for performing the procedure in the operating room.
“It is like practice for a baseball game,” he said. “If you do not practice, your game will not be as good. Furthermore, in the operating room, residents do not have the time to look around the knee, for example, and catch some nuances because they need to keep things moving for the sake of the patient. In the skill lab, they can spend a lot more time just looking and learning a good sense of three-dimensional anatomy,” he said.
Williams expressed concern that simulation does not become a substitute for the apprenticeship model.
“I hope the use of simulators does not take the place of actual one-on-one interaction with faculty mentors and surgeons who help and train the residents on using the equipment and interacting in surgery,” he said. “Residency should always be an apprenticeship model where faculty takes pride in teaching a junior resident on improving their skills.”
Cannada stressed the need for evaluating how much orthopedic trainees are learning through simulation, how much they are retaining and whether simulation is helping trainees to be better surgeons. “If trainees have never seen the specific type of cases they are learning in simulation, then they are not going to retain that information in the modules,” she said. “We need to judge how much they are retaining, and I think the surgical skills would be better introduced in the first year and targeted in the second and third years.”
Future for orthopedic trainees
“The future for orthopedic surgeons is exceptionally bright,” Kuivila said. “It is a dynamic specialty; we are learning more and more about the basic science of bone and cartilage repair, and hopefully in another generation, we will be putting in far fewer knee replacements because we will be able to grow new cartilage. Tissue engineering is taking off in such a way that there will be different ways to do better biologic repairs rather than replacing bones with metal. In addition, our understanding of scoliosis and spine surgery improves on a yearly basis.”
With that said, Kuivila stressed the importance of residents and surgeons staying abreast of the latest advances in the field. He cautioned that in 10 years, orthopedic residents may not be doing any more than 50% of the operations they learned in residency. “Because change is constant, surgeons need to be accepting of that and recognize that in the field of orthopedics, things continue to change at an ever-increasing rate,” he said. “They need to keep themselves up to date on how things are changing and focus their practice on evidence-based medicine.”
Residents currently leaving formal training must also recognize that they will need to respond to changes that will occur outside of clinical practice in terms of government regulation and oversight. “There are a lot of people picking away at the orthopedic surgeons and the medical community at large,” Kuivila said. “Residents need to be proactive and involved in their professional organizations. Otherwise, someone else is going to be telling us exactly how to do things and we are going to have little autonomy. It is important to be involved and give a little pushback when you see things that are not necessarily in the best interest of the patients.” – by Tina DiMarcantonio
Fabricant PD. J Grad Med Educ. 2013;doi:10.4300/JGME-D-12-00081.1.
Froelich J. J Surg Ed. 2009;doi:10.1016/j.jsurg.2008.12.007.
Levine WN. J Am Acad Orthop Surg. 2014;doi:10.5435/JAAOS-22-09-535.
For more information:
Lisa K. Cannada, MD, can be reached at the Department of Orthopaedic Surgery, Saint Louis University, 3635 Vista Ave., 7th Floor Desloge Tower, St. Louis, MO 63110; email: firstname.lastname@example.org.
Orrin I. Franko, MD, can be reached at the Orthopaedic Surgery Resident Training Program, University of California, San Diego, 350 Dickinson St., MC 8894, San Diego, CA 92103; email: email@example.com.
Thomas Kuivila, MD, can be reached at the Cleveland Clinic, Mail Code A40, 9500 Euclid Ave., Cleveland, OH 44195; email: firstname.lastname@example.org.
William N. Levine, MD, can be reached at the Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, 161 Fort Washington Ave., New York, NY 10032; email: email@example.com.
Ann E. Van Heest, MD, can be reached the Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Ave. S., Suite 200, Minneapolis, MN 55454; email: firstname.lastname@example.org.
Phillip N. Williams, MD, can be reached at the Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021; email: email@example.com.
Disclosures: Cannada, Franko, Kuivila, Levine, Van Heest and Williams have no relevant financial disclosures.
What are the benefits and disadvantages of using simulation for orthopedic trainees?
Benefits outweigh disadvantages
W. Dilworth Cannon
The benefits of simulation training far outweigh any disadvantages (cost of simulators). In 1927, William Mayo said there is no excuse today for the surgeon to learn on the patient. Eighty-six years later, in 2013, the Accreditation Council for Graduate Medical Education issued a requirement that residency programs have surgical skills training as part of their curriculum. Surgical simulation would be one part of this requirement. As the general public becomes more educated, they will demand more accountability for surgical interventions. In the aviation industry, pilots could not hold down a job without proof of simulation training. Surgical simulation should decrease the incidence of surgical errors and speed up completion of surgical cases. Mistakes on the simulator are harmless and are rectified by repeated deliberate practice on the simulator. The use of simulation to demonstrate surgical skills may become a requirement for certification or maintenance of certification for practicing orthopedic surgeons in the future.
There are few papers and orthopedic literature that have demonstrated transfer of training (transfer validity) from a simulator to the operating room. We published a paper in the November 2014 issue of the Journal of Bone and Joint Surgery validating the ArthroSim high-fidelity virtual reality simulator (Touch of Life Technologies; Denver). Forty-eight postgraduate year (PGY)-3 residents from seven academic institutions were randomly assigned to a simulation-trained or control group. The simulation-trained group had to train on the simulator to reach a predetermined level of proficiency in visualization and probing skills while performing a diagnostic knee arthroscopy. Both groups then performed a diagnostic arthroscopy on a live patient under the supervision of an attending surgeon. We then analyzed the DVD recordings using a proprietary checklist. The simulation-trained group statistically significantly outperformed the control group. Probing skills were even more significant. Visualization tasks alone were not statistically significant, nor was the rating using a global rating scale, but it would have been statistically significant if an extreme outlier had been eliminated.
In a preliminary pilot study, we found that the simulator was able to show statistically significant differences in skill level between PGY-1 residents and both PGY-5 residents and community-based orthopedic surgeons, but not between the latter two groups.
Based on the results of our study, we can infer that junior residents’ surgical skills would be enhanced by training on an arthroscopic simulator before beginning their arthroscopic operating room experience.
W. Dilworth Cannon, MD, is a professor of clinical orthopedic surgery at the University of California-San Francisco.
Disclosure: Cannon has no relevant financial disclosures.
Cannon WD. J Bone Joint Surg. 2014;doi:10.2106/JBJS.N.00058.
Cannon WD. J Bone Joint Surg. 2014; doi:10.2106/JBJS.M.00779.
Simulation more effective with validated curriculum, use of metrics
The literature is replete with documentation of surgeons who have higher volumes of specific procedures having fewer complications and improved outcomes over those performing similar procedures on an infrequent basis. A learning curve exists for the acquisition of surgical skills and procedural techniques. Traditionally, a substantial portion of the progress up that learning curve has taken place after a surgeon begins practice and operates in the clinical setting. Patient morbidity and suboptimal outcomes are the probable consequences. Simulation for surgery has the potential to afford the opportunity for the trainee to obtain and refine surgical skills in an “inconsequential” manner (i.e., without morbidity to the patient). Although improving surgical skills will be a lifelong endeavor for the practicing surgeon, mastering fundamental techniques prior to performing surgery in the clinical setting can be expected to reduce errors and improve outcomes.
The use of surgical simulation, by itself, will not ensure that the trainee will become a more skilled surgeon. A carefully constructed and validated curriculum must form the foundation and precede the employment of the simulator. The specific task on which to be trained must be identified and then corresponding metrics should be created for that task that are clear, objective, measurable and achievable. The trainee must know not only how to execute the proper technique, but also the potential errors to be avoided. Once the metrics for the essential tasks and ultimately those of a particular procedure are validated, simulations/simulators can be designed specifically to mimic that experience and train those skills.
Richard L. Angelo
A misconception often exists that the higher the fidelity of a simulator, the better and more effective it will be. The task on which to be trained should be identified first. Low-level and mid-level fidelity simulators are generally better for training basic and intermediate-level techniques, and ‘virtual reality’ (VR) simulators more appropriate to train for complete operations. As an example, learning the fundamental techniques involved in intracorporeal knot tying is best done with knot-tying boards, progressing to delivery of a knot down a cannula, to working beneath an opaque dome (Arthroscopy Association of North America [AANA] Fundamentals of Arthroscopic Surgery Training [FAST] workstation) requiring the surgeon to view an image of the knot projected on a laptop screen. A VR simulator to accomplish similar training would be much more expensive and have difficulty providing the same tactile experience as the simpler tools identified.
A recent study conducted by AANA (Copernicus Initiative) highlighted the role and impact of a medium-fidelity simulator for the acquisition of arthroscopy skills. A set of metrics was developed and validated for an arthroscopic Bankart repair. Forty-four residents were randomly assigned to one of three training groups: A) traditional lecture/cadaver practice, B) identical training to group A with the additional use of a shoulder model simulator, and C) proficiency-based training (PBP; specific skill sets must be acquired and demonstrated to progress) in concert with the same simulation. Group B (simulator exposure) demonstrated a modest 1.8-times increased probability in meeting a predetermined benchmark compared with the control group A, whereas group C showed a 5.5-times increased probability over group A in achieving the same benchmark. Thus, the simulator itself, without the PBP curriculum, was marginally effective at improving the desired skills.
Surgical simulation advantages include the following:
- providing the trainee with “synthetic experience” with the opportunity to move up the learning curve for the acquisition of surgical or procedural skills;
- permitting the trainee to enact procedural/technique errors in an “inconsequential” manner (no patient morbidity) and to learn from those errors to improve their technique;
- enabling the trainee to engage in repetitive practice;
- providing the acquisition of trainee performance data, which document progress toward a predetermined benchmark (for higher-fidelity simulators); and
- providing trainee performance data that guide subsequent training sessions to focus on deficiencies exhibited.
Surgical simulation disadvantages include the following:
- the simulator, by itself without a preexisting validated curriculum, may be ineffective in improving the skill sets necessary to train essential surgical techniques;
- practice on the simulator without specific, defined performance goals has the potential to ingrain poor habits/skills;
- essential proximate feedback is not provided to the trainee for low- and medium-fidelity simulators; and
- more expensive simulators used without a validated curriculum may result in poor “value” for training institutions.
Richard L. Angelo, MD, is affiliated with ProOrtho Clinic in Kirkland, Wash.
Disclosure: Angelo has no relevant financial disclosures.
Simulation most effective with proficiency-based progression
Let me begin by stating my support for simulation as it applies to surgical training. It is here to stay and will play an important role moving forward. The Accreditation Council for Graduate Medical Education has mandated that training programs implement a surgical skills curriculum. To comply, innovative protocols will be needed, and simulation will provide a safe environment and will serve as a versatile teaching tool.
The difficult part for many of us is in defining simulation. There are those who have focused on high-fidelity haptics and the creation of virtual-reality simulators. W. Dilworth Cannon, MD, and his workgroup are to be credited with the development of such a device for the knee, the ArthroSim (Touch of Life Technologies; Denver). Yet, can a knot-tying board and strand of rope, both exceedingly “low-tech,” constitute simulation? The short answer is yes. With such a wide-ranging definition of simulation, we must be careful in simply embracing the concept without more scrutiny.
At the Arthroscopy Association of North America (AANA) Annual Meeting in 2014, Frank and colleagues presented a systematic review evaluating the utility of modern arthroscopic simulators in training surgical residents. The conclusion from that review simply reinforced the concept that simulators can be helpful in providing a safe environment for skills training. They also concluded that practice on a simulator leads to improved performance on the simulator. The transfer of training into the operating room was not established in their systematic review. Recently, Cannon and his colleagues published their experience with the ArthroSim and confirmed that transfer of training was successfully achieved. Cannon and his co-authors are to be commended for their efforts; however, the published results indicated that of the three major identified metrics, only one met statistical significance. In particular, their global rating scale and their visualization metric failed to meet significance. The finding that training can be transferred is a critical concept, and in this setting, the high-fidelity haptics and virtual reality were essential to the investigation.
There is perhaps a more cogent approach to the use of simulation, and it places simulation subservient to an identified educational process that has been validated as the most effective method for teaching surgical skills. The proficiency-based progression (PBP) model, which has been vigorously tested as part of the AANA Copernicus Initiative, represents the new paradigm shift in surgical training. Richard L. Angelo, MD, presented the results of his multicenter, prospective, randomized, blinded trial comparing PBP training with the ubiquitous apprenticeship training model in the acquisition of surgical skills. Using proximate feedback and validated criteria for successful completion of tasks that represented the fundamentals of a deconstructed procedure, those participating in PBP training had to successfully master each metric of the procedure before advancing to the next step. With a well-defined goal and validated benchmarking, those who underwent PBP were seven times more likely to achieve proficiency when compared with those who followed the more traditional training methods. All subjective criteria were eliminated from the process, and the ability to objectively analyze and score a metric formed the basis for this dramatic paradigm shift. During the clinical trial used to evaluate the PBP model, knot-tying boards with rope, plastics models and cadavers were all used effectively to instruct the participants. This is where simulation has its greatest impact. Simulation in its most advanced iteration, or at its nadir, is most effective in its service to an advanced and validated curriculum. Although simulation as a standalone tool has merit, its greatest impact will be in its ability to enhance a proven methodology.
Richard K.M. Ryu, MD, is affiliated with the Ryu Hurvitz Clinic in Santa Barbara, Calif.
Disclosure: Ryu is a consultant for DePuy Mitek, MedBridge and Rotation Medical.
Angelo RL. Results from the Arthroscopy Association of North America (AANA) Copernicus Initiative: A multicenter, prospective, randomized, blinded trial of proficiency-based progression training employing simulation for an arthroscopic Bankart procedure. Presented at: Arthroscopy Association of North America Annual Meeting; May 1-3, 2014; Hollywood, Fla.
Cannon WD. J Bone Joint Surg. 2014;doi:10.2106/JBJS.N.00058.
Frank R. Paper #SS-70. Presented at: Arthroscopy Association of North America Annual Meeting; May 1-3, 2014; Hollywood, Fla.