William Kraemer

Orthopedic boot camp: examining the effectiveness of an intensive surgical skills course.

BACKGROUND Changes in health care across the globe have had a profound impact on the number of hands-on surgical training opportunities that are available to residents. In the current study, we examine whether an intensive laboratory-based skills course at the start of orthopedic surgical training is an effective mechanism for teaching core technical skills. METHODS First-year residents were divided into 3 groups (on-service, n = 8; off-service, n = 8; and a new, competency-based program that has as a major element of the curriculum a focused, intensive skills laboratory-based experience, n = 6). Baseline surgical skills were assessed prior to commencing training. The intensive skills laboratory group was then given an intensive surgical skills course, whereas the other 2 groups embarked on traditional residency. After the surgical skills course, all the residents were assessed for core surgical skills using an objective structured assessment of technical skills (OSATS) procedure. RESULTS Pretraining scores revealed no differences between the groups of residents using both checklist (F[2,19] = 0.852, P = .442) and global rating scores (F[2,19] = 0.704, P = .507). Post-training scores revealed a significant difference, with residents from the intensive skills laboratory group performing better on both the checklists (on-service = 78.9, off-service = 78.6, intensive skills laboratory = 92.3; F[2,19] = 6.914, P < .01) and global rating scores (on-service = 3.4, off-service = 3.4, intensive skills laboratory = 4.3; F[2,19] = 5.722, P < .01), than the other groups who showed no differences between them. CONCLUSION The intensive skills course used in this study was highly effective at teaching and developing targeted surgical skills in first-year orthopedic residents. We predict that allowing residents to acquire key technical skills at the start of their training will enhance learning opportunities at later stages of training.

Three-Year Experience with an Innovative, Modular Competency-Based Curriculum for Orthopaedic Training

In response to multiple stresses in current surgical education, we developed a new model of orthopaedic training that combines curricular reform with a competency-based framework. For the past three years, this pilot program has been run in parallel to our conventional curriculum for a select number of residents. In this article, we share our initial experience with this approach to training and describe its successes and challenges. We review the existing concerns with surgical training in a new era of work-hour restrictions and describe the pedagogical rationale for the model that we have developed. We then discuss the design of this curriculum, including the basic tenets and principles that guided our approach. Finally, we detail our preliminary results, which add evidence that a focused, modular-based program, with concentrated teaching of technical skills and frequent formative and summative evaluations, can result in rapid acceleration in surgical competency, knowledge acquisition, and comprehensive professional skills. This new model deserves further study and consideration for implementation on a broader scale in today’s challenging medical education environment. There have been questions about our general approach to surgical education for quite some time. Charles Bosk catalogued some of the good and much of the bad that went along with residency education a quarter of a century ago1. Similarly, William Nolan2 described the rigors of surgical training in Bellevue Hospital in New York, NY. The reverberations from The Bristol Royal Infirmary Inquiry3 sparked a focus on the issue of patient safety. This issue was reinforced with the dissemination of the Institute of Medicine report, To Err Is Human: Building a Safer Health System 4. Preoccupation with the issue of patient safety has led to many positive outcomes in patient care, but an important side effect has been decreased opportunities for residents for …

Reflections on Competency-Based Education and Training for Surgical Residents

Although a number of surgical training institutions have started to adopt competency-based education (CBE) frameworks for training, the debate about the value of this model continues. Some proponents regard CBE as a method of guaranteeing residents competence, whereas others consider CBE to be reductive and lacking the richness in experiences that the traditional model offers. In this article, we reflect on CBE and review some salient attempts to implement CBE in surgical education. We identify challenges facing postgraduate surgical education, some of which are motivating educators to consider incorporating CBE into their curricula. We look at some purported advantages and disadvantages of CBE and describe initial reports from CBE programs currently being developed.

Orthopaedic Boot Camp II: Examining the retention rates of an intensive surgical skills course

BACKGROUND We examined retention rates for basic surgical skills taught through a 1-month intensive laboratory boot camp-style course at the onset of residency. METHODS We present data from 3 groups, each composed of 6 residents. The first group consisted of residents from a new competency-based curriculum (CBC). They started residency training with the Toronto Orthopaedic Boot Camp course. The other 2 groups were junior (JR) and senior (SR) residents from a traditional program whose residency training included no such course. Performance on targeted technical skills was tested using an objective structured assessment of technical skills examination 7 months after the onset of training for the CBC and JR groups and at least 43 months after the onset of training for the SR group. RESULTS The mean global rating scale score for the CBC group immediately after the skills course was 4.3, which was maintained 6 months later. There were no significant performance differences between the CBC and SR groups. Both the CBC and SR groups performed significantly better than the JR group (mean global rating scale 3.7; F[2, 15] = 12.269, P < .001). CONCLUSION We conclude that a surgical skills course at the onset of residency is an effective mechanism for teaching targeted technical skills and that skills taught in this manner can have excellent retention rates. Furthermore, an early focus on technical skills allows junior residents to perform at the same level as senior residents for certain tasks and may privilege later learning.

Micromotion secondary to axial, torsional, and shear loads in two models of cementless tibial components

Tibial component loosening and lack of bone ingrowth remain serious problems in uncemented knee arthroplasty. Initial implant stability is the most important factor in achieving bone ingrowth. Eccentric axial loading causing liftoff has been identified as a potential problem, but the role of torsion and shear stability is unclear. This study assesses the micromotion in two uncemented components subjected to eccentric axial (lateral, medial, posterior, anterior), shear, and torsional loads. Four configurations were tested: Tricon M (pegs) (Smith and Nephew Richards, Memphis, TN), Genesis (stem only) (Smith and Nephew Richards), Genesis with screws, and Genesis with pegs. Nine pairs of cadaver tibias were implanted, and cyclic loads were applied. Micromotion was measured with two linear variable differential transformers. Micromotion values for each mode of loading were compared using a one-way analysis of variance. Genesis with screws had the least micromotion for all applied loads (14-33 micrometers), whereas Genesis with stem only has the maximum value of micromotion (27-212 micrometers). Genesis wit and Tricon had intermediate ranges of micromotion (32-121 and 107-140 micrometers, respectively). It is concluded that peg fixation and stem fixation are inadequate and result in significant micromotion. Stem plus screws provides the most stable fixation and may be compatible with bone ingrowth.

Simulation for Teaching Orthopaedic Residents in a Competency-based Curriculum: Do the Benefits Justify the Increased Costs?

BackgroundAlthough simulation-based training is becoming widespread in surgical education and research supports its use, one major limitation is cost. Until now, little has been published on the costs of simulation in residency training. At the University of Toronto, a novel competency-based curriculum in orthopaedic surgery has been implemented for training selected residents, which makes extensive use of simulation. Despite the benefits of this intensive approach to simulation, there is a need to consider its financial implications and demands on faculty time.Questions/purposesThis study presents a cost and faculty work-hours analysis of implementing simulation as a teaching and evaluation tool in the University of Toronto’s novel competency-based curriculum program compared with the historic costs of using simulation in the residency training program.MethodsAll invoices for simulation training were reviewed to determine the financial costs before and after implementation of the competency-based curriculum. Invoice items included costs for cadavers, artificial models, skills laboratory labor, associated materials, and standardized patients. Costs related to the surgical skills laboratory rental fees and orthopaedic implants were waived as a result of special arrangements with the skills laboratory and implant vendors. Although faculty time was not reimbursed, faculty hours dedicated to simulation were also evaluated. The academic year of 2008 to 2009 was chosen to represent an academic year that preceded the introduction of the competency-based curriculum. During this year, 12 residents used simulation for teaching. The academic year of 2010 to 2011 was chosen to represent an academic year when the competency-based curriculum training program was functioning parallel but separate from the regular stream of training. In this year, six residents used simulation for teaching and assessment. The academic year of 2012 to 2013 was chosen to represent an academic year when simulation was used equally among the competency-based curriculum and regular stream residents for teaching (60 residents) and among 14 competency-based curriculum residents and 21 regular stream residents for assessment.ResultsThe total costs of using simulation to teach and assess all residents in the competency-based curriculum and regular stream programs (academic year 2012–2013) (CDN 155,750, USD 158,050) were approximately 15 times higher than the cost of using simulation to teach residents before the implementation of the competency-based curriculum (academic year 2008–2009) (CDN 10,090, USD 11,140). The number of hours spent teaching and assessing trainees increased from 96 to 317 hours during this period, representing a threefold increase.ConclusionsAlthough the financial costs and time demands on faculty in running the simulation program in the new competency-based curriculum at the University of Toronto have been substantial, augmented learner and trainer satisfaction has been accompanied by direct evidence of improved and more efficient learning outcomes.Clinical RelevanceThe higher costs and demands on faculty time associated with implementing simulation for teaching and assessment must be considered when it is used to enhance surgical training.

Cognitive and Psychomotor Entrustable Professional Activities: Can Simulators Help Assess Competency in Trainees?

BackgroundAn entrustable professional activity describes a professional task that postgraduate residents must master during their training. The use of simulation to assess performance of entrustable professional activities requires further investigation.Questions/purposes(1) Is simulation-based assessment of resident performance of entrustable professional activities reliable? (2) Is there evidence of important differences between Postgraduate Year (PGY)-1 and PGY-4 residents when performing simulated entrustable professional activities?MethodsThree entrustable professional activities were chosen from a list of competencies: management of the patient for total knee arthroplasty (TKA); management of the patient with an intertrochanteric hip fracture; and management of the patient with an ankle fracture. Each assessment of entrustable professional activity was 40 minutes long with three components: preoperative management of a patient (history-taking, examination, image interpretation); performance of a technical procedure on a sawbones model; and postoperative management of a patient (postoperative orders, management of complications). Residents were assessed by six faculty members who used checklists based on a modified Delphi technique, an overall global rating scale as well as a previously validated global rating scale for the technical procedure component of each activity. Nine PGY-1 and nine PGY-4 residents participated in our simulated assessment. We assessed reliability by calculating the internal consistency of the mean global rating for each activity as well as the interrater reliability between the faculty assessment and blinded review of videotaped encounters. We sought evidence of a difference in performance between PGY-1 and PGY-4 residents on the overall global rating scale for each station of each entrustable professional activity.ResultsThe reliability (Cronbach’s α) for the hip fracture activity was 0.88, it was 0.89 for the ankle fracture activity, and it was 0.84 for the TKA activity. A strong correlation was seen between blinded observer video review and faculty scores (mean 0.87 [0.07], p < 0.001). For the hip fracture entrustable professional activity, the PGY-4 group had a higher mean global rating scale than the PGY-1 group for preoperative management (3.56 [0.5] versus 2.33 [0.5], p < 0.001), postoperative management (3.67 [0.5] versus 2.22 [0.7], p < 0.001), and technical procedures (3.11 [0.3] versus 3.67 [0.5], p = 0.015). For the TKA activity, the PGY-4 group scored higher for postoperative management (3.5 [0.8] versus 2.67 [0.5], p = 0.016) and technical procedures (3.22 [0.9] versus 2.22 [0.9], p = 0.04) than the PGY-1 group, but no difference for preoperative management with the numbers available (PGY-4, 3.44 [0.7] versus PGY-1 2.89 [0.8], p = 0.14). For the ankle fracture activity, the PGY-4 group scored higher for postoperative management (3.22 [0.8] versus 2.33 [0.7], p = 0.18) and technical procedures (3.22 [1.2] versus 2.0 [0.7], p = 0.018) than the PGY-1 groups, but no difference for preoperative management with the numbers available (PGY-4, 3.22 [0.8] versus PGY-1, 2.78 [0.7], p = 0.23).ConclusionsThe results of our study show that simulated assessment of entrustable professional activities may be used to determine the ability of a resident to perform professional tasks that are critical components of medical training. In this manner, educators can ensure that competent performance of these skills in the simulated setting occurs before actual practice with patients in the clinical setting.

Student-led learning: a new teaching paradigm for surgical skills

BACKGROUND Competency-based education and simulation are being used more frequently in surgical skills curricula. We explored a novel student-led learning paradigm, which allows trainees to become more active participants in the learning process while maintaining expert guidance and supervision. METHODS Twelve first-year orthopedic residents were randomized to either a student-led (SL) or a traditional instructor-led group during an intensive, month-long, laboratory-based technical skills training course. A rigorous qualitative-description approach was used for analysis. RESULTS Four prominent themes emerged: instructional style, feedback, peer and instructor collaboration, and self-efficacy. Compared with the instructor-led group, there was more peer assistance, feedback, collaboration, and hands-on and active learning observed in the SL group. CONCLUSIONS The flexible and socially rich nature of the SL learning environment may aid in development of both technical and nontechnical skills early in residency and ultimately privilege later clinical learning.

Board 383 - Research Abstract Examining the Effects of a Student-Led Learning Paradigm in a Simulation-Based Surgical Skills Course (Submission #564)

Introduction/Background Recent changes in healthcare training, such as increasing demands on faculty time, reduced opportunities for teaching in the clinical setting and increasing awareness for patient safety, have led medical educators to rely more on simulation-based programs to supplement traditional clinical teaching.1–4 One such program is the Toronto Orthopaedic Boot Camp (TOBC), an intensive course designed to teach core surgical skills to incoming orthopaedic residents at the University of Toronto.5 Data from this program have revealed that it is possible to persistently advance the technical skills of first year residents to the level of senior residents for targeted tasks after just one month.6,7 However, technical skill development is only one aspect of surgical training and there is a recognized need to emphasize non-technical skills and promote professional identity formation.8,9 In the present study, we investigate the impact of implementing a student-led learning (SLL) paradigm on the early acquisition of non-technical skills. Methods Twelve incoming orthopaedic residents participated in this research, which was embedded in the month long TOBC skills course. Residents were randomly divided into two groups: six were taught using a new paradigm focused on supervised, student-led exploration and practice (SL group), while the other six were taught using a traditional, instructor-led paradigm (IL group).6,7 A typical day consisted of a didactic teaching session followed by an extended practical session in a simulation laboratory, with the instructional methodology governed by the assigned paradigm. Trained observers systematically documented the interactions that took place over the course of the month. Upon completion of the program, residents completed self-efficacy and exit questionnaires. Confidential interviews were conducted with the residents and primary instructors and senior faculty were polled for informal observations. Field observation notes were analyzed thematically. Interview responses were transcribed, checked for accuracy and analyzed for common themes by two independent raters. We then used a qualitative outcomes analysis approach to interpret our findings. Results Residents from both SL and IL groups were able to perform the targeted technical skills to an acceptable standard by the end of the TOBC program. We observed differences in the non-technical skills acquired by the two groups. SL participants exhibited more peer-to-peer interactions and both asked and were asked more interpretative questions. SL residents also reported feeling a greater sense of control over their learning than their IL counterparts. Interviews revealed that the IL group regarded their instructors as resources who could teach them the task at hand, whereas the SL group described their instructors as facilitators, offering guidance when asked but allowing them to explore skills and techniques for themselves. The instructors reported more cooperation and collegiality amongst the SL group. Conclusion Student-led learning was found to effectively promote and enhance interactions both between peers and also between trainees and their instructors. The SL paradigm also afforded residents pedagogic space to direct their own learning, which enabled them to feel more in control of the learning process. All of the traits promoted by the SL paradigm are known to contribute to effective learning,10–15 as well as the development of professional identity.16–19 The flexible and socially rich nature of the SL paradigm also appears to promote effective decision making, teamwork and leadership skills.9,20,21 Anecdotal reports from senior faculty suggest that this approach may lead to a better understanding of several core CanMEDS roles early in residency. 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