Orthopaedic surgeons as educators. Applying the principles of adult education to teaching orthopaedic residents

Surgical skills training for practicing surgeons founded on established educational theories and frameworks

Following completion of structured training in residency or fellowship programs, surgeons need to acquire new skills throughout their careers to address changes in their surgical practices, and to perform new procedures and use new technologies as these are developed. The opportunities available to surgeons to acquire the new skills, safely introduce these skills into surgical practice, and then maintain the skills, vary greatly and may not fully support a surgeon's needs. The article shares background information relating to the vexing problems, and describes established educational theories and frameworks as well as specific frameworks relating to surgical skills training and verification that may be used in designing and implementing comprehensive and impactful surgical skills training programs aimed at practicing surgeons. A number of practical strategies based on these theories and frameworks are highlighted. National professional organizations and academic medical centers need to play a critical role in pursuing such efforts, which will remain pivotal in supporting the professional work of surgeons and in providing optimal surgical care well into the future.

Feedback in an Epidemic?

Undergraduates and postgraduates frequently receive feedback on their clinical and non-clinical performance and progression throughout their studies and career. Good quality feedback has been shown to improve trainees’ confidence and performance. This article discusses the benefits of feedback and reviews the communication, technical, financial, and networking barriers to feedback introduced by coronavirus disease 2019 (COVID-19) and its impact on the quality of medical and dental education in the UK, followed by a critical reflection. In addition, it reviews the pros and cons of self-assessment of clinical learning, and it provides an overview of the most widely accepted feedback models: Pendleton’s rules, SET-GO method, agenda-led, outcome-based analysis (ALOBA) model and Prepare to Ask-Discuss-Ask-Plan Together (Prepare to ADAPT) on the quality of feedback received. The aim is to identify the most suitable feedback method to help trainees with their clinical and professional development during the COVID-19 pandemic and any possible pandemics in the future.

How to Create an Arthroscopy Training Laboratory Using a Bovine Knee Model

Orthopaedic surgeries by video arthroscopy have become increasingly popular, as they allow joint treatment through small incisions and minimal tissue damage. However, their execution requires specific skills from the surgeon, different from open surgery, which can only be achieved through practical training. These skills would be ideally performed on human cadaveric anatomical pieces which, however, can be difficult to access for different reasons. Animal anatomical models for surgical skills training have been used for years in medicine, and we observed that the bovine knee has anatomical characteristics quite similar to that of the human knee. In this study, we explain, step by step, the installation and creation of an arthroscopy laboratory with a bovine model, in an effort to contribute to several training centers in arthroscopic surgery around the world, assisting and guiding such centers to install arthroscopy laboratories and facilitating the improvement of more surgeons.

COVID-19 as a disruptor: innovation and value in a national virtual fracture conference

Objectives:

The aim of this study was to determine the educational value of a national virtual fracture conference implemented during the COVID-19 disruption of resident education.

Design:

Survey study.

Setting:

National virtual conference administered by the Orthopaedic Trauma Association.

Participants:

Attendees of virtual fracture conference.

Intervention:

Participation at a national virtual fracture conference.

Main outcome measure:

Surveys of perception of quality and value of virtual conferences relative to in-person conferences.

Results:

Ninety-six percent of participants rated the virtual fracture conference as similar or improved educational quality relative to conventional in-person fracture conference. Participants also felt they learned as much (35%) or more (57%) at each virtual fracture conference compared to the amount learned in-person. The quality of interpersonal interactions at both the resident–faculty level and faculty–faculty level was also perceived to be overall superior to those at participants’ own institutions. Learners felt they were more likely to engage the primary literature as well. Overall, 100% of participants were likely to recommend virtual conference to their colleagues and 100% recommended continuing this conference even after COVID-19 issues resolve.

Conclusions:

We found that learners find significant educational value in a national virtual fracture conference compared to in-person fracture conferences at their own institution. COVID-19 has proven to be a disruptor not only in health care but in medical education as well, accelerating our adoption of innovative and novel resident didactics.

Level of Evidence:

Therapeutic Level III.

Utilizing Intraprocedural Interactive Video Capture With Google Glass for Immediate Postprocedural Resident Coaching

BACKGROUND

Video coaching has been found to be an effective teaching method because it incorporates many of the established principles of successful adult learning. The goal of our study was to assess the feasibility and effectiveness of using a point-of-view video camera (Google Glass) to improve the surgical skills education of orthopaedic surgery residents.

METHODS

Forty-two residents from 4 institutions participated in a partially blinded randomized control trial performing an intra-articular distal tibial fracture reduction task while wearing Google Glass to record the performance. Participants underwent a structured coaching session with 20 participants (intervention group) using the recorded video to augment this session, and 22 participants (control group) receiving verbal coaching alone. The task was repeated again immediately after the coaching session. Performance was scored using an Objective Structured Assessment of Technical Skills checklist, Global Rating Scale, fluoroscopic usage, and reduction quality. A semistructured interview was then performed to assess experience of participants.

RESULTS

There was no significant difference (p > 0.05) seen in score improvement in the Objective Structured Assessment of Technical Skills checklist, Global Rating Scale, fluoroscopic usage, or reduction quality between the control and intervention groups. Thematic analysis of interview showed majority of participants found video coaching increased effectiveness in understanding of goals, developing techniques and strategies, and process of self-reflection. Their involvement was seen overall as a positive experience, with participants wanting to see more inclusion of video coaching within surgical education.

CONCLUSIONS

No difference in performance improvement between the 2 groups was seen, but majority of participants found the video coaching sessions valuable and could have potential beneficial role in education.

Deliberate teaching tools for clinical teaching encounters: A critical scoping review and thematic analysis to establish definitional clarity

PURPOSE AND METHOD

We conducted a scoping review of tools designed to add structure to clinical teaching, with a thematic analysis to establish definitional clarity.

RESULTS

Six thousand and forty nine citations were screened, 434 reviewed for eligibility, and 230 identified as meeting study inclusion criteria. Eighty-nine names and 51 definitions were identified. Based on a post facto thematic analysis, we propose that these tools be named "deliberate teaching tools" (DTTs) and defined as "frameworks that enable clinicians to have a purposeful and considered approach to teaching encounters by incorporating elements identified with good teaching practice." We identified 46 DTTs in the literature, with 38 (82.6%) originally described for the medical setting. Forty justification articles consisted of 16 feedback surveys, 13 controlled trials, seven pre-post intervention studies with no control group, and four observation studies. Current evidence of efficacy is not entirely conclusive, and many studies contain methodology flaws. Forty-nine clarification articles comprised 12 systematic reviews and 37 narrative reviews. The most number of DTTs described by any review was four. A common design theme was identified in approximately three-quarters of DTTs.

CONCLUSIONS

Applicability of DTTs to specific alternate settings should be considered in context, and appropriately designed justification studies are warranted to demonstrate efficacy.

A Porcine Knee Model Is Valid for Use in the Evaluation of Arthroscopic Skills: A Pilot Study

BACKGROUND

Previously validated knee arthroscopy evaluation tools have used human cadaveric knees. This is unsustainable because of the cost and scarcity of these specimens. Porcine (pig) knees are anatomically similar, affordable, and easily obtainable; however, whether porcine knees represent a suitable alternative to human specimens has not been evaluated.

QUESTIONS/PURPOSES

The purpose of this study was to determine whether porcine knees are similar to human cadaveric knees for the assessment of knee arthroscopy skills by evaluating (1) the validity of the porcine model (whether trainees of the same level of ability scored similarly when using the two models) and (2) the reliability of the porcine model (whether surgeons with experience achieved higher scores than surgeons with less experience in the porcine model).

METHODS

Eleven orthopaedic surgery residents (five junior residents and six senior residents), one orthopaedic sports medicine fellow, and three attending orthopaedic surgeons were enrolled. Participants were provided instructions for a proper arthroscopic examination of the knee and asked to identify, and then probe, the listed anatomic structures on both the human and porcine knee specimens. Each participant was asked to demonstrate the following skills: joint manipulation, instrument control and triangulation, fluid management, maintenance of field of view, economy of movement, and efficiency. The Objective Assessment of Arthroscopic Skills (OAAS) and checklist for diagnostic arthroscopy of the knee were used for skills assessment by one observer. Internal consistency, a measure of how well the assessment tool measures the skills being studied, was determined by Cronbach's α and group differences investigated by paired t-test and Wilcoxon signed-rank tests where appropriate. Based on a sample size calculation, a total of 37 subjects would be required for the full-scale research study to achieve a power of 0.80, with α set at 0.05, to detect a difference in OAAS score of 4.73 (25%). This value is outside of the 95% confidence intervals for the human knee.

RESULTS

We found the porcine model to have a high level of face validity. There was no difference with the numbers available in total OAAS scores (mean ± SD; 95% confidence interval [CI]) within subjects between the human (18.93 ± 7.54; 14.76-23.11) and porcine (17.87 ± 6.36; 14.34-21.39) knees (p = 0.433). There was also no difference (p = 0.234) with the numbers available in overall OAAS score among participants working on either human (2.60 ± 1.35; 1.85-3.35) or porcine (2.33 ± 0.90; 1.84-2.83) specimens. Internal consistency of the simulation for both the human and porcine knees was high and did not differ between groups (Cronbach's α was 0.919 in the human knee and 0.954 in the porcine knee), suggesting the OAAS outcome score specifically assesses arthroscopic skill of participants in both the human and porcine models. More experienced arthroscopists scored higher than did less experienced trainees; there was high correlation (Pearson's correlation coefficient r, 95% CI) between years of experience and total OAAS scores in human (0.78; 0.46-0.92) and porcine (0.80; 0.49-0.93) diagnostic arthroscopy models.

CONCLUSIONS

The porcine cadaveric knee model was a valid surrogate for the human knee in arthroscopic skills assessment.

CLINICAL RELEVANCE

Trainees can be objectively evaluated using an affordable model that allows summative and formative feedback in the laboratory at a fraction of the cost of previously validated methods.

Objective Structured Clinical Examinations: a guide to development and implementation in orthopaedic residency

Objective Structured Clinical Examinations (OSCEs) have been used extensively in medical schools and residency programs to evaluate various skills, including the six core competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). Orthopaedic surgery residency programs will be required by the ACGME to assess residents on core competencies in the Milestone Project. Thus, it is important that evaluations be made in a consistent, objective manner. Orthopaedic residency programs can also use simulation models in the examination to accurately and objectively assess residents' skills as they progress through training. The use of these models will become essential as resident work hours are decreased and opportunities to observe skills become more limited. In addition to providing a method to assess competency, OSCEs are a valuable tool for residents to develop and practice important clinical skills. Here, we describe a method for developing a successful OSCE for use in orthopaedic surgical resident training.

Application of the "see one, do one, teach one" concept in surgical training

BACKGROUND

The traditional method of teaching in surgery is known as "see one, do one, teach one." However, many have argued that this method is no longer applicable, mainly because of concerns for patient safety. The purpose of this article is to show that the basis of the traditional teaching method is still valid in surgical training if it is combined with various adult learning principles.

METHODS

The authors reviewed literature regarding the history of the formation of the surgical residency program, adult learning principles, mentoring, and medical simulation. The authors provide examples for how these learning techniques can be incorporated into a surgical resident training program.

RESULTS

The surgical residency program created by Dr. William Halsted remained virtually unchanged until recently with reductions in resident work hours and changes to a competency-based training system. Such changes have reduced the teaching time between attending physicians and residents. Learning principles such as experience, observation, thinking, and action and deliberate practice can be used to train residents. Mentoring is also an important aspect in teaching surgical technique. The authors review the different types of simulators-standardized patients, virtual reality applications, and high-fidelity mannequin simulators-and the advantages and disadvantages of using them.

CONCLUSIONS

The traditional teaching method of "see one, do one, teach one" in surgical residency programs is simple but still applicable. It needs to evolve with current changes in the medical system to adequately train surgical residents and also provide patients with safe, evidence-based care.

Validation of a global assessment of arthroscopic skills in a cadaveric knee model

PURPOSE

The purpose of this study was to determine whether a global assessment of arthroscopic skills was valid for blinded assessment of cadaveric diagnostic knee arthroscopy.

METHODS

A global skills assessment for arthroscopy was created using a published theory of the development of expertise. Faculty surgeons, fellows, and residents were consented and enrolled in this institutional review board-approved validation study. All participants were oriented to the equipment and procedures for diagnostic arthroscopy of the knee. After reviewing the anatomic structures to be visualized, participants were allowed 10 minutes to complete a diagnostic arthroscopy of the knee. The hands and arthroscopic view were recorded during this attempt. Resident participants completed a second filmed diagnostic arthroscopy 1 week after the initial attempt. Five blinded reviewers watched the synchronized videos and assessed arthroscopic skills with a procedure-specific checklist and the newly developed global skills assessment. The agreement between reviewers was determined by intraclass correlation coefficient. Internal consistency was determined with Cronbach's α. Test-retest reliability was measured by correlating repeated arthroscopies by residents. The ability of the global assessment to discriminate skill levels was determined with between-group Mann-Whitney U tests.

RESULTS

The agreement between global assessment scores was strong (I.C.C. = 0.80, 95% C.I. 0.68-0.92). The internal consistency of evaluations was excellent (Cronbach's α = 0.97), and the test-retest reliability was strong (r = 0.52). The global assessment score was shown to be able to discriminate between skill levels by an analysis of variance indicating the difference in means among the various levels of training (P < .0001).

CONCLUSIONS

The Objective Assessment of Arthroscopic Skills is a useful adjunct to arthroscopic educators and learners and could be used for in-training evaluations.

CLINICAL RELEVANCE

The Objective Assessment of Arthroscopic Skills is an instrument that can be employed to measure the impact of skills curricula, including but not limited to simulation.

Orthopaedic in-training examination performance: a nine-year review of a residency program database

BACKGROUND

The Orthopaedic In-Training Examination (OITE) provides an objective way for both the residency program and the resident to monitor progress.

METHODS

This longitudinal descriptive study tracks the OITE performance of 16 residents from one orthopaedic surgery residency program over nine years (1997-2005). Domain comparisons are made to national averages (N > 3000) by mean difference and split middle celeration line assessment trend analysis to evaluate program strengths and weaknesses. Further evaluation by postgraduate year (PGY) is made of domains that were deemed to be in need of moderate attention.

RESULTS

Resident performance for the medically related issues, rehabilitation, and sports medicine domains were deemed acceptable. Resident performance on the orthopaedic science, orthopaedic diseases, hip and knee reconstruction, spine, and shoulder and elbow domains were deemed to be in need of minor attention. Musculoskeletal trauma, pediatric orthopaedics, foot and ankle, and hand domains were deemed to be in need of moderate attention. Further analysis of these domains by PGY revealed less positive slopes for the pediatric orthopaedics and musculoskeletal trauma domains, and a negative slope for the hand domain between PGY-3 and PGY-4, each indicative of lower domain-specific OITE scores than the national mean. A similar, less positive slope was identified between PGY-2 and PGY-3 for the foot and ankle domain.

CONCLUSIONS

A longitudinal descriptive review of orthopaedic surgery resident OITE performance enables the departmental education committee to identify curricular content areas that require attention, select the most efficient modes of educational information delivery, facilitate learning through the application of innovative educational technologies, establish measurable educational program goals, and more prescriptively allocate personnel and equipment resources.