Resident Training in 2009: It's the quality of time and not the quantity that matters

William Kraemer, M.D., FRCSC
Benjamin Alman, M.D., FRCSC
Richard Reznick, M.D., M.Ed, FRCSC
Toronto, ON 

Our current time-based system of training residents was introduced by William Halsted at Johns Hopkins Hospital in 18891. 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 director2.

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 Europe3,4 and the U.S.5 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 training15.

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 end 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 authorities2,6,7,8,9,10. There is evidence that acquisition of technical skills can be hastened by a competency-based program versus the standard time-based approach6,7.9,12,13, and by providing residents with ample opportunities for deliberate practice6. 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 known14. Acquisition of certain neurosurgical procedures was noted to be achieved 18 months earlier in a competency-based approach compared to standard time-based training2. 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 curriculum11. 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.

References 

  1. Carter B.N. The fruition of Halsted's concept of surgical training. Surgery 1952; 32:52-27.
  2. Long D.M. Competency-based Residency Training: The Next Advance in Graduate Medical Education. Acad Med. 2000; 75:1178-83.
  3. Council Directive 93/104/EC. Official Journal of the European Communities 1993;L307:18-24.
  4. Pickersgill T. The European working time directive for doctors in training. BMJ 2001;323:1266
  5. Leach D.C. A model for GME: shifting from process to outcomes - a progress report from the Accreditation Council for Graduate Medical Education. Med Educ 2004;38:12-14.
  6. Reznick R., MacRae H. Teaching surgical skills - changes in the wind. NEJM 2006;355:2664-9.
  7. Carraccio C. Shifting paradigms: from Flexner to competencies. Acad Med 2002;77:361-367.
  8. Cate O. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007; 82:542-547.
  9. Bhatti N. Competency in surgical residency training: defining and raising the bar. Acad Med. 2007; 82:569-573.
  10. Meyers F. Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med. 2007; 82:1211-1219.
  11. Reznick R, Bohnen J. Summary of the University of Toronto Department of Surgery Retreat of Residency Education: Proposal for a Model for Change. 2005. (Unpublished)
  12. Brown A.K., O'Connor P.J. et al. Ultrasonography for rheumatologists: the development of specific competency based educational outcomes. Ann Rheum Dis 2006;65;629-636.
  13. Dowson C., Hassell A. Competence-based assessment of specialist registrars: evaluation of a new assessment of out-patient consultations. Rheum 2006;45:459-464.
  14. Rasmussen J. Skills, rules, knowledge: signals, signs and symbols and other distinctions in human performance models. IEEE Trans Systems, Man and Cybernetics. 1983;123:257-66.
  15. Anglen J., Bosse M., Bray T., Pollak A., Templeman D., Tornetta P., Watson J. The Institute of Medicine Report on Resident Duty Hours: The Orthopaedic Trauma Association Response to the Report. JBJS 2009; 91:720-2.

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