Scroll down to respond to the OrthopaedicsOne Poll: We should replace our current time-based training system with one that is competency-based
The current emphasis on operating room efficiency along with a greater emphasis on avoiding medical errors has resulted in decreased resident independence in the operating room. This trend has resulted in a competence-based residency training program which is in complete contrast to the well established time-based training system. Drs. William Kraemer, Benjamin Alman, Richard Reznick, and Timothy Carey discuss the merits and drawbacks of both systems.
Viewpoint 1: William Kraemer, Benjamin Alman, Richard Reznick
It’s the Quality of Time and Not the Quantity that Matters
Our current time-based system of training residents was introduced by William Halsted at Johns Hopkins Hospital in 1889. The fundamental requirements of a Halsted residency were a fixed period of time for training, structured educational content, actual experience with patients, escalating responsibility for patient care during training, and a period of supervised practice after formal training. This system remains the cornerstone of surgical training in North America more than a century later.
A significant disadvantage of the current system is that the time required for training is chosen arbitrarily and does not take into account individual variation in the time required to learn procedural skills, decision making and judgment. The continuous changes in the specialty have been accommodated by the inclusion of fellowships of equally arbitrary duration. Issues of competency and professionalism have been left to the judgment of the program director.
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The training environment has changed dramatically over the last decade. An emphasis on operating room efficiency, an increased complexity of cases and a greater emphasis on mitigating medical error has resulted in decreased resident independence. Resident work hour restrictions in Europe and the U.S. have inevitably made their way to Canada. The Institute of Medicine Report on Resident Duty Hours generated major concern on the part of the Orthopaedic Trauma Association as to the negative effect on patient care and resident training, and the possible need to lengthen residency training.
While there are many benefits to limiting work hours, such as less educational time or clinical activity when fatigued due to lack of sleep, these changes have also shortened the number of hours available for hands-on clinical training. There are a number of non-negotiables that fix the length of the work week, including maximum rates of call, early post-call dismissal, academic half days and principles of surgery curricula, maternity and paternity leave, vacation, and conference leave. The result is that residents are graduating with less clinical and operative skills than their teachers.
While many applaud a departure from the often intolerable work demands of residency programs of the past, the irony is the net result may be a lengthening of surgical programs. This would be unfortunate, as the average age of a graduating specialist in Canada is 33 and extends to 36 if he or she has pursued advanced training. Rather than increase the length of residency training programs, it would be preferable to make better use of that time by considering alternate methods of curricular delivery.
Calls for competency-based training programs to replace the current time-based system have emanated from medical schools, certifying bodies, and licensing authorities.2,6-10 There is evidence that acquisition of technical skills can be hastened by a competency-based program versus the standard time-based approach,6,7,9,11,12 and by providing residents with ample opportunities for deliberate practice.
Rasmussen theorizes that the first step in a practical learning system must be the acquisition of skills, and asserts that these skills can be learned before the full theoretical knowledge required for their practical application is known. Acquisition of certain neurosurgical procedures was noted to be achieved 18 months earlier in a competency-based approach compared to standard time-based training. It is unclear if judgment and decision making can similarly be hastened, but presumably there is individual variation in the attainment of these skills as well.
Many of these issues were crystallized in a retreat held by the Department of Surgery, University of Toronto, which articulated the essentials for a competency-based focused approach to a surgical curriculum. This was the impetus for the Division of Orthopaedic Surgery to develop a competency-based curriculum which we will trial with three residents in a proof of principle experiment. It consists of 21 modules that cover all aspects of orthopaedic surgery, including all of the objectives of Core Training in Surgery and Orthopaedic Specialty Training Requirements of the Royal College of Physicians and Surgeons of Canada.
To implement the curriculum, one faculty member is designated as the module leader and will oversee all aspects of his/her assigned module. Progress from one module to the next is based on achieving the breadth of objectives in that module rather than time spent. The modules are divided into three phases reflecting the increasing complexity of successive modules; eg, basic fracture fixation, arthroscopy and arthroplasty are in phase 1. These concepts and skills are reviewed and expanded in phase 3 with complex trauma, revision arthroplasty and advanced arthroscopy. Longitudinal maintenance and repetition of skills will also be accomplished by participation in regular orthopaedic on call experiences.
Extensive use will be made of cadavers, a skills laboratory and simulation activities to ramp up the pace of technical skill acquisition and serve as an adjunct for operative experiences. Multiple methods of formative and summative assessment of all the CanMEDS roles will be used to evaluate progress of the residents in the competency-based program.
When all of the modules have been completed, a comprehensive assessment of the competency-based residents will be carried out and compared to the regular stream graduating residents to ensure non-inferiority of the pilot program. Although not the primary goal, there is significant potential to reduce training time in this program.
The competency-based curriculum was approved by the Royal College of Physicians and Surgeons of Canada as an alternate stream in the orthopaedic residency training program, and the pilot project with three residents will commence on July 1, 2009. We are not aware of any other residency training program that has trialed an entirely competency-based curriculum. We look forward to reporting the results and anticipate supporting the assertion that it is the quality of time and not the quantity that matters in residency training.
Reprinted with permission from the Summer 2009 issue of the COA Bulletin
References
- Carter BN, 1952. “The fruition of Halsted’s concept of surgical training.” Surgery 32 (3): 518-27
- Long DM, 2000. “Competency-based residency training: the next advance in graduate medical education.” Acad Med 75 (12): 1178-83
- Pickersgill T, 2001. “The European working time directive for doctors in training.” BMJ 323 (7324): 1266
- Leach DC, 2004. “A model for GME: shifting from process to outcomes. A progress report from the Accreditation Council for Graduate Medical Education.” Med Educ 38 (1): 12-4
- Anglen JO, Bosse MJ, Bray TJ, Pollak AN, Templeman DC, Tornetta P, Watson JT, 2009. “The Institute of Medicine report on resident duty hours. Part I: The Orthopaedic Trauma Association response to the report.” J Bone Joint Surg Am 91 (3): 720-2
- Reznick RK, MacRae H, 2006. “Teaching surgical skills — changes in the wind.” N Engl J Med 355 (25): 2664-9
- Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C, 2002. “Shifting paradigms: from Flexner to competencies.” Acad Med 77 (5): 361-7
- ten Cate O, Scheele F, 2007. “Competency-based postgraduate training: can we bridge the gap between theory and clinical practice?” Acad Med 82 (6): 542-7
- Bhatti NI, Cummings CW, 2007. “Competency in surgical residency training: defining and raising the bar.” Acad Med 82 (6): 569-73
- Meyers FJ, Weinberger SE, Fitzgibbons JP, Glassroth J, Duffy FD, Clayton CP, , 2007. “Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force.” Acad Med 82 (12): 1211-9
- Brown AK, O’Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P, 2006. “Ultrasonography for rheumatologists: the development of specific competency based educational outcomes.” Ann Rheum Dis 65 (5): 629-36
- Dowson C, Hassell A, , 2006. “Competence-based assessment of specialist registrars: evaluation of a new assessment of out-patient consultations.” Rheumatology (Oxford) 45 (4): 459-64
Viewpoint 2: Timothy Carey
Opinion Against Competence-Based Residency Training
Residency training in the surgical specialties has a long history. Over the years educators have continually tried to refine the techniques used to impart the surgical knowledge and skills necessary to produce safe competent surgeons to serve society. Recently, a fairly radical proposal has been made with respect to the timing of surgical training. It has been suggested that surgical training time can be compressed by adopting a curriculum based on attainment of specific competencies as a replacement for the traditional time-based curriculum.
Competency-based training is predicated on the concept that there are different learning curves for individuals and that those differences should be recognized in medical education. It is proposed that after an individual succeeds in mastering a skill set in orthopaedic training, he or she should be certified in that aspect of training. In this model, the entire curriculum is broken into modules of training, and the progression through training is based purely on attainment of certification in each module until the total training is complete. In this way, the duration of training is variable for every resident, and obviously the more “advanced” trainee can finish in a shorter period of time.
On the surface this appears to be an attractive idea from a number of aspects. Certainly in these days of doctor shortages, the possibility of producing physicians in a more efficient and timely manner has appeal. However, upon closer examination of the concept, a number of potential problems become obvious and bring into question the feasibility of such an approach.
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From a purely practical viewpoint, designing such a program would present major logistical challenges. At present, residents are a vital part of the patient care team. The inability to predict the time a trainee would spend on a given service would obviously have a significant impact on the organization of patient care in teaching hospitals. The resident’s role would need to be supplemented by physician extenders and other allied health professionals, at significant additional cost.
Surgical training in particular is an extremely demanding undertaking in medical education. Not only are we trying to impart a breadth and depth of knowledge about clinical conditions, but we are also charged with developing the technical skills necessary to perform the required intervention. The technical aspect of surgical training can be likened to an apprenticeship, with a foundation of core skills developed by repetition and then expanded into ever more complex treatment schemes. Ultimately the apprentice becomes skillful enough to work without supervision, and then graduates to solo practice.
Another analogy is that of an airline pilot, who, in order to develop enough skill to become certified as an expert, requires a minimum number of hours flying in progressively more senior levels of responsibility. This is a particularly apt comparison, as in both flying and surgery, the task is one that has very serious consequences in the case of errors. To protect the public, rigorous training conditions are enforced and graded responsibility is an important component of training.
In his book Outliers, Malcolm Gladwell explores the attainment of expert status in many different fields. One of the most important concepts he explores is the “10,000 hour rule”, which refers to the recurrent theme in the backgrounds of all the experts identified. No matter what field of endeavour, the best of the best could identify a prolonged period of repetitive practice at their chosen activity totaling on average at least 10,000 hours. In addition, there was a direct correlation in the level of achievement and the time spent in practice even at levels less than 10,000 hours. Is there any reason we should assume that this doesn’t apply to orthopaedic surgery?
The most significant problem in competency-based training will likely be the development of appropriate assessment tools. The concept implies that a definable skill set exists and has been defined for each module, and that these skills can be objectively measured both accurately and reproducibly. While it is true that the educational literature demonstrates the ability to teach some surgical tasks efficiently and effectively in this modular fashion, for the large part these studies are focused on specific manual tasks, eg, application of a plate to a bone.
An accurate assessment of how many cases are required to achieve a passing grade for a specific competency has yet to be defined, and even a specific number of cases may not be sufficient to determine competence. Merely recording the number of total knee joint surgeries the resident has scrubbed in on, for example, will be useless information unless the degree of responsibility can be documented and the outcomes of those specific cases graded objectively. The complexity of acquiring and interpreting this data is daunting to say the least, and many subspecialty areas have a much wider range of procedures to be considered.
A complete orthopaedic surgeon is much more than a technician, and the ability to develop the skills necessary to be a caring, empathetic physician able to accurately diagnose and treat the myriad musculoskeletal conditions that comprise a modern day orthopaedic practice is only achieved by exposure and repetition.
The development of the CanMEDS framework was a direct response to the public demand for more approachable, engaged physicians. It is difficult to see how these important competencies such as communicator and collaborator could be “signed off” on at some time during training in isolation. It is only with repeated encounters with patients and their families, in progressively more responsible roles, that the trainee develops the ability to break the news about a diagnosis of a tumour, or comfort the family whose child has sustained a serious fracture, or discuss end-of-life care with the family of an elderly patient with a hip fracture. There is no substitute for experience in these situations, and only time will allow enough exposure for the trainee to become comfortable with this important role.
The goal of our training programs should be to produce as complete a physician as possible. Generally speaking, the residents that tend to stand out in training programs demonstrate excellent judgment and professionalism in addition to clinical acumen and surgical skill. The current training system, while by no means perfect, has evolved over many years to enable us to produce excellent orthopaedic surgeons, and should not be abandoned until there is clear evidence that similar results can be achieved with newer training methods.
Additional Reading
Frank JR, Langer B. Collaborator, communicator, manager and advocate: teaching surgeons new skills through the CanMEDS project. World J Surg 2003 Aug;27(8):972-78.
Grantcharov TP, Reznick RK. Training tomorrows surgeons: what are we looking for and how can we achieve it? ANZ J Surg 2009 Mar;79(3):104-7.
Sachdeva AK. Acquisition and maintenance of surgical competence. Semin Vasc Surg 2002 Sept;15(3):182-90.