Dempsey S. Springfield, M.D.

Graduate medical education is changing rapidly. HCORP, as is the case for all residency programs, struggles with attempting to make the modifications and provide the best education possible to the HCORP residents. There are a variety of reasons for the changes. The ACGME felt the pressure from the Institute of Medicine (IOM) and the public to reduce fatigue among residents and to improve the quality of graduates. Residencies felt the pressure of hospital efficiency efforts, which reduce the time an individual patient is hospitalized and therefore reduce the opportunity for residents to learn about the patient. Faculty are expected to support themselves and their clinical activities with practice funds. Hospitals are under increasing pressure to cut costs and the Federal Government has reduced its financial support for resident education. For surgical residences an additional issue is the dramatic increase in outpatient surgery.

Residency education is becoming more standardized and formal. Every rotation is expected to have specific goals and objectives for each level of resident. This means, for example, that the Sports Service must have a set of goals and objective for all six competencies for both the PGY-2 and PGY-5 resident. This may seem over prescriptive, but it does mean that faculty must decide what they want the resident to learn and what they are going to teach. It also facilitates doing meaningful evaluations because the expectations are clear. This concept is new to faculty, and few of us were taught orthopaedics with this structure. Once the faculty become accustom to this structure I believe the quality of education will increase.

Duty hour limitations remain controversial. It does not seem possible that Libby Zion’s death, which began the examination of resident fatigue, happened 28 years ago (1984). New York State instituted their duty hour restrictions 14 years later (1998), but the ACGME did not require duty hour restrictions until 2003. We had time to manage the problem of fatigue, but we missed the opportunity and now we have the blunt tool of duty hour limits, which few believe is the best solution. Duty hour restrictions have been criticized by those who believe they produce a “shift-worker” mentality and require too many “hand-offs” between treating teams. Residencies will not go back to the time when there were no limits on duty hours, and that is a good thing. We need to learn how to work as teams rather than individuals. The best medical care is done by a team of physicians with the support of nurses, an assortment of therapist, and administrative personnel. Physicians cannot do it alone. The more we become team players (we are and will remain the quarterback) the better care we provide.

Orthopaedic surgical procedures continue to increase in complexity, and more are done with the aid of an arthroscope, microscope, or robot. This makes surgical education more difficult and time consuming. The most likely solution is the use of simulation so a resident can gain a level of skill that justifies allowing them to “practice” on a human patient. Designing simulation programs, having residents do simulated surgery, and the evaluation of competency all take time and money, neither of which is in abundance. Despite this it must be done.

These challenges are real, and the solutions are not obvious. George Dyer, MD became the HCORP Program Director in April of 2012 and has the responsibility of assuring the HCORP residents that they are and will be well educated and prepared to practice orthopaedic surgery when their five years are completed. I wish him the best.

Dempsey S. Springfield, MD