Changes are needed in the programs that train orthopedic surgeons to ensure these doctors are adequately trained, according to a study by researchers at Hospital for Special Surgery (HSS) in New York City. The study, which analyzed feedback from heads of orthopedic programs around the country, appears in the January issue of the Journal of Bone and Joint Surgery.
"Before this study, we at Special Surgery thought that we were the only hospital dealing with these complicated challenges," said Laura Robbins, DSW, vice president of education and academic affairs at HSS. "As a result of this study, we have come to realize that as a nation, the prominent training programs around the country are grappling with these same issues."
Because the field of training surgeons in general, and particularly orthopedic surgeons, has changed dramatically, investigators at HSS set out to identify the challenges faced by programs. They invited input from heads of well-established orthopedic residency programs across the country including New York University School of Medicine, University of California at Los Angeles Medical Center, Duke University School of Medicine, Johns Hopkins University School of Medicine, and Case Western Reserve University. The study analyzed survey responses from 17 heads of orthopedic programs around the country and feedback from 12 of these individuals gathered during a two-day meeting held at HSS.
Participants were asked to evaluate whether the traditional residency model is appropriate for the training of future surgeons and to discuss current approaches that have been successfully implemented in orthopedic training programs. The group identified four basic areas of need: addressing compromises to the learning experience caused by work-hour restrictions, identifying a body of core orthopedic knowledge with specific goals and expectations, developing common benchmarks to measure and improve program effectiveness, and addressing the challenges caused by generational differences between faculty and residents.
"One of the biggest factors challenging the education of orthopedic surgeons is the work-hour restrictions which have severely affected what residents are able to learn and do within the five years of training," Dr. Robbins said. "The public has read a lot in the media about work-hour restrictions for trainees, particularly surgeons. The Institute of Medicine recommended back in July that they would not tolerate any violations to the work hour restrictions -- being that residents work no more than 24 hours, have shift breaks and one day off in seven. While we are meeting that mandate, it is a big challenge, because the resident no longer treats the patient from pre-surgery to post-surgery, greatly compromising the learning of continuity of care."
Dr. Robbins pointed out that patients may suffer as well. While physician assistants and hospitalists step in, so the resident can go home, nobody truly knows the patient from beginning to end. "The resident traditionally used to be the one person who knew the patient from the beginning of care to the end of care, because they were here during the day and during the night on call," Dr. Robbins said. "The issue today gets to the heart of patient safety and quality." The Accreditation Council for Graduate Medical Education first instituted work-hour restrictions in 2003.
Dr. Robbins said a solution to this problem has not been identified yet. "Most programs are saying we really need to look at the curriculum and modify the residents' rotations, so that the resident gets the exact training and experience they need, but what that is specifically is unknown at this point," she said.
Another big issue identified was addressing generational and gender differences. "The residents of today are a very different generation than the current senior surgeons. They approach training very differently in that they have multiple priorities, becoming good surgeons while they juggle family and extra activities as a whole. The trainees and the surgeons of the past were more focused on their careers first," Dr. Robbins said. Residents today also want to learn via electronic technology, which is vastly different from the way older surgeons learned. Dr. Robbins reported that programs are lagging behind in providing educational modalities via electronic technology. On a gender front, more women are going into orthopedic surgery and there are more challenges like maternity leave affecting programs.
Dr. Robbins added that orthopedic programs need to accept more trainees into programs. The number of residents accepted into orthopedic programs has been capped for more than 20 years, but there is an increasing demand for orthopedic surgeons. "We know from projections in studies that there won't be enough orthopedic surgeons in the future for the baby boomers who will need joint replacements," Dr. Robbins said. "The groups that establish how many trainees you have and how many surgeons you need really need to be looking at this and making some very broad sweeping recommendations."
According to Dr. Robbins, there was a sense from the two-day meeting that the American Medical Association and the American Board of Orthopedic Surgeons are concerned that there is a problem. However, there have not been any solid recommendations. "The common theme is that we have a problem as a country in training the orthopaedic surgeons of tomorrow yet there are no specific solutions," said Dr. Robbins. "Our goal is to bring back this group in the Spring to focus on coming up with specific recommendations."
Dr. Robbins is also an associate scientist in the research division at Hospital for Special Surgery and an associate research professor of social work in medicine, Weill Cornell Medical College. Other authors of the study include Mathias Bostrom, M.D.; Edward Craig, M.D.; and Thomas Sculco, M.D.
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