Abstract
Introduction
The educational paradigm for orthopaedic surgeons is shifting from a strictly Operating Room based approach to the addition of simulator- and lab-based models. This study aims to assess resident views on the relative value of orthopaedic educational resources and the value of a cadaver-based arthroscopy skills laboratory.
Method
A questionnaire assessing beliefs about various orthopaedic educational resources for overall orthopaedic education and surgical skills education was given to all residents in one orthopaedic residency program with a new arthroscopic skills laboratory during a three year period. Forty-one orthopaedic residents from years PGY1 through PGY5 participated.
Results
Observation and participation in the OR was the highest ranked learning activity for both overall and surgical skills education. Sessions in the skills lab ranked second for surgical skills education and fourth for overall orthopaedic education. The arthroscopic skills lab was most highly valued for practicing 3-D use of instruments and developing familiarity with equipment.
Conclusions
Orthopaedic trainees highly value operating room experience as the primary resource for education during residency. Orthopaedic trainees have found the addition of a surgical skills training lab for teaching arthroscopic skills a significant benefit to both their overall education and to surgical skills training.
Introduction
There are currently approximately 150 orthopaedic training programs in the United States producing approximately 620 graduates annually1. Orthopaedic training programs have been guided by the American Board of Orthopaedic Surgery (ABOS) since 19342. However, the educational curriculum for orthopaedic training is not standardized and varies considerably among programs. There are three main goals of orthopaedic training: 1) education in the diseases and conditions that are common to the field of orthopaedic surgery, 2) education in the pertinent basic and clinical sciences, and 3) education in the procedural skills and operative techniques of orthopaedics. The third goal encompasses knowledge of the operation details, equipment utilized, and the practice of technical skills. All three goals are integrated in the process of developing surgical judgment in orthopaedic residents.
Educational resources in orthopaedics include didactic lectures, experience in the operating room, and experience in the clinical setting while caring for patients. Additional knowledge is gained from reading orthopaedic texts and journals, and from web-based resources. Recently, other skills-based learning opportunities have become more prevalent within orthopaedic surgery. Residency programs have opted to develop surgical skills labs where techniques and skills are taught and practiced on simulators, plastic models or cadaveric specimens. In addition, orthopaedic organizations, societies, and industry-funded education and surgical training courses using cadaveric specimens are prevalent and are frequently used by residents either as a formal part of a residency program’s curriculum, or to supplement existing program activities. The potential benefit these labs offer is increased opportunities for residents to gain familiarity with surgical equipment, procedures, and techniques in a low-risk, low-cost environment.
Paradigm shifts in surgical education have encouraged orthopaedic residency programs across the country to invest in surgical skill laboratories to provide relatively low-cost opportunities for residents to develop familiarity with equipment and techniques3. The residents at the investigator’s program spend approximately 90 minutes per week practicing arthroscopic procedures on cadaveric knee, shoulder, ankle and elbow specimens as a formal part of the curriculum. Residents are required to attend these sessions during their “sports medicine” rotations. Instruction during these teaching sessions is directed by a faculty member or a current sports medicine fellow. Senior [Post graduate year (PGY) 4 and 5] residents also instruct more junior residents (PGY2). At the time of this study residents spent 4 months as a PGY2, 4 months as a PGY4, and 2 months as a PGY5 on rotations where arthroscopy was routinely performed and a significant part of the surgical experience.
Despite the variety of educational resources and curricula, little is known regarding the value of the individual components to orthopaedic education. The author’s department recently invested in building and equipping a surgical skills and arthroscopy laboratory to enhance the teaching of surgical anatomy and surgical skills with an emphasis on arthroscopy. However, the relative value of a surgical skills lab in the realm of resident and fellow education has not previously been evaluated. Hence, the purpose of this study was twofold. First, the study was to gauge the subjective importance of various educational resources available to orthopaedic surgery residents. Secondly, the subjective benefits of using an arthroscopic skills lab utilizing cadaveric specimens in an orthopaedic training curriculum were assessed. We hypothesized that the use of a surgical skills laboratory would be favorably received by orthopaedic residents at all levels.
Methods
All orthopaedic residents and trainees were asked to complete a survey at the end of three academic training years regardless of their participation in formal skills lab teaching sessions that year or not. The surveys were administered in 2005, 2006, and 2009. The survey was composed of questions related to the relative value of several common orthopaedic educational resources. The resources included: didactic lectures and conferences, case-based lectures and conferences, textbooks, teaching videos, observation and participation in the operating room, surgical skills teaching lab sessions, clinic teaching, teaching from senior residents / fellows / colleague trainees, and journal articles. These survey questions required the trainee to rank order the available educational resources from most to least important. The resources were separately rank ordered in terms of importance for overall orthopaedic education and importance for surgical skills education. The nine rankings were categorized into three groups: upper third (ranks 1-3), middle third (ranks 4-6) and lower third (ranks 7-9).
Multiple potential benefits of using a cadaveric specimen for learning and practicing arthroscopic surgical skills were queried. The questions and responses applicable to this part of the study are included in Table 1. For the purposes of this study, only the first response for a resident with more than one response was included.
Table 1.
Resident questions and responses pertaining to the usefulness of arthroscopy practice on a cadaveric knee specimen
| Question | Response Options |
|---|---|
| How beneficial did you find practicing on the cadaveric knee specimen? | Not beneficial at all |
| How beneficial did you find practicing on the cadaveric knee specimen in becoming familiar with basic arthroscopy equipment? | Slightly beneficial |
| How beneficial did you find direct teaching from the faculty, fellows and other trainees while practicing on the cadaveric knee specimen? | Somewhat beneficial |
| How beneficial was practicing on the cadaveric knee specimen in regards to practicing three-dimensional use of instruments? | Very beneficial |
| How beneficial was practicing on the cadaveric knee specimen in regards to becoming familiar with procedure instruments? | Extremely beneficial |
| How beneficial was practicing on the cadaveric knee specimen in regards to becoming familiar with procedure techniques? | |
| How beneficial was practicing on the cadaveric knee specimen in regards to becoming familiar with normal arthroscopic anatomy? | |
| Did the arthroscopy skills sessions increase your confidence in doing OR cases? | No, not at all |
| Did the arthroscopy skills sessions help you be faster and more efficient doing OR cases? | Yes, confidence increased slightly |
| Did the arthroscopy skills sessions increase your ability to participate in more of the OR cases? | Yes, speed and efficiency increased moderately |
| Did the arthroscopy skills decrease the incidence of damage to normal structures during case? | Yes, speed and efficiency increased significantly |
Pearson’s chi-square tests of independence were conducted to assess differences in frequency distribution of trainee responses by year in training.
Results
A total of 56 surveys were completed at the end of three academic years. Forty-one different trainees completed surveys during this time and these were included in this analysis. The demographic data and post graduate levels of the trainees completing the surveys are summarized in Table 2.
Table 2.
Gender and year in training of respondents
| Frequency (%) | |
|---|---|
| Gender | N = 41 |
| Male | 37 (80.4) |
| Female | 4 (19.6) |
| Year in Training | N =41 |
| PGY1 | 7 (17.1) |
| PGY2 | 5 (12.2) |
| PGY3 | 12 (29.3) |
| PGY4 | 2 (4.9) |
| PGY5 | 14 (34.1) |
| Fellow | 1 (2-4) |
The educational resources that orthopaedic trainees found most useful for both overall orthopaedic training and surgical skills training are listed in the Table 3. For both overall and surgical skills training, observation and participation in the OR was considered most valuable with 85% (34/40) of respondents ranking it in the top third for overall training and 95% (38/40) ranking it in the top third for surgical skills training. 95% (38/40) of residents ranked skills lab sessions in the first third for surgical skills training but only 35% (14/40) ranked skills lab sessions in the top third for overall orthopaedic education. Residents perceived observation/participation in the OR, teaching from fellows and colleagues, teaching in the clinic and skills lab sessions as most important to overall orthopaedic education. Observation/participation in the OR, skills lab sessions, teaching from fellows and colleagues and teaching videos were perceived as most valuable to surgical skills education. Journal articles were perceived as having the least value for learning in both educational areas.
Table 3.
Elements of orthopeadic training and their perceived value to orthopaedic residents (n = 41)
| Value to overall orthopaedic education | Value to surgical skills education | |||||
|---|---|---|---|---|---|---|
| Rank 1-3 N (%) | Rank 4-6 N (%) | Rank 7-9 N (%) | Rank 1-3 N (%) | Rank 4-6 N (%) | Rank 7-9 N (%) | |
| Observation/participation in OR | 34(85.0) | 6 (15.0) | - | 38(95.0) | 2(5.0) | - |
| Skills lab sessions | 14(35.0) | 18 (45.0) | 8 (20.0) | 38(95.0) | 2(5.0) | - |
| Teaching: clinic | 19 (47.5) | 12(30.0) | 9 (22.5) | 1(2.6) | 7(17.9) | 31(79.5) |
| Teaching: sr. residents/fellows/colleagues | 26(65.0) | 10(25.0) | 4(10.0) | 24(61.5) | 11(28.2) | 4(10.3) |
| Teaching: videos | 5(12.5) | 7(17.5) | 28(70.0) | 15(37.5) | 21(52.5) | 4(10.0) |
| Case-based lectures and conferences | 10(25.0) | 24(60.0) | 6(15.0) | 1(2.5) | 18(46.2) | 20(51.3) |
| Didactic lectures and conferences | 5(12.5) | 18(45.0) | 17(42.5) | 3(7.7) | 8(20.5) | 28 (71.8) |
| Textbook readings | 5(12.5) | 12(30.0) | 23(57.5) | 1(2.6) | 31(79.5) | 7 (17.9) |
| Journal articles | 2(5.0) | 12(30.0) | 26(65.0) | 1(2.4) | 17(41.5) | 23(56.1) |
Note: Number of respondents varies due to missing data.
Skills laboratory sessions were perceived by the majority of respondents as being beneficial (Table 4). Almost half (48.7%) of the respondents considered skills lab sessions to be extremely beneficial for practicing three-dimensional (3-D) use of instruments. All respondents considered the skills lab sessions to be at least somewhat beneficial for practicing 3-D instrument use. Over 80% (30/37) of respondents perceived skills lab sessions to be very to extremely beneficial for developing basic familiarity with arthroscopic equipment. Teaching by faculty/fellows was considered to be least beneficial with close to half (48.7%) of respondents perceiving it to be no more than somewhat beneficial.
Table 4.
Perceived benefits of skills laboratory sessions (n = 37)
| Not/Slightly Beneficial N (%) | Somewhat Beneficial N (%) | Very Beneficial N (%) | Extremely Beneficial N (%) | |
|---|---|---|---|---|
| Familiarity with basic arthroscopy equipment | 2(5.4) | 5(13.5) | 21(56.8) | 9(24.3) |
| Familiarity with arthroscopic instruments | 4(10.8) | 7(18.9) | 19(51.4) | 7(18.9) |
| Familiarity with arthroscopic anatomy | 6(16.2) | 8(21.6) | 13(35.2) | 10 (27.0) |
| Practicing 3D use of instruments | - | 5(13.5) | 14(37.8) | 18(48.7) |
| Learning procedure techniques | 3(8.3) | 7(19.4) | 14(39.0) | 12(33.3) |
| center Teaching by faculty/fellows | 4(10.8) | 14(37,9) | 13(35.1) | 6(16.2) |
Note: Number of respondents varies due to missing data.
Table 5 summarizes resident perception of the value of skills lab sessions to the OR experience. Over half the respondents reported a moderate increase in confidence, speed and efficiency, and participation in OR cases as a result of skills lab sessions. Amount of participation in the OR was perceived as the domain least affected by practice in the arthroscopy skills lab with 30% (10/33) of respondents reporting no or only a slight increase. Over 80% (27/33) of the respondents reported that confidence in the OR increased at least moderately as a result of practice in the arthroscopy skills lab.
Table 5.
Perceived benefits in the OR associated with the use of an arthroscopy skills lab (n = 33)
| No Increase N (%) | Slight Increase N (%) | Moderate increase N (%) | Significant increase N (%) | |
|---|---|---|---|---|
| Confidence in the OR | -- | 6(18.2) | 18 (54.5) | 9 (27.3) |
| Speed and efficiency in the OR | 1 (3.0) | 8(24.3) | 17 (51.5) | 7 (21.2) |
| Participation in OR case | 4(12.1) | 6(18.2) | 17 (51.5) | 6 (18.2) |
No significant differences in resident responses relative to year in training were observed.
Discussion
Orthopaedic education has evolved into a multifaceted activity, integrating established teaching methods with new technologies. These changes are, in part, the result of recently implemented restrictions in resident work hours, increased pressure for clinical productivity at academic teaching institutions and technological advances. Despite these changes, little research has been done to evaluate either the subjective value of learning experiences or objective measures of learning success in orthopaedic residents. To develop a better understanding of what educational activities residents value for learning orthopaedic surgery, we conducted a survey of residents in one program at an academic medical center.
Survey respondents in this orthopaedic program identified operating or assisting in the operating room as by far the most important educational resource for both overall orthopaedic learning and surgical skills learning. This is not surprising in that most orthopaedic residents choose this field based on interest in the surgical aspect of orthopaedics and most residents enjoy time in the operating room. Even the best models outside the OR cannot duplicate the full OR experience.
Education from peers was also valued highly for both overall orthopaedic education and for surgical skills education. This may reflect the educational model of the investigating institution where residents primarily work in teams of 2-4 residents of varying seniority. Teaching by senior residents may benefit both junior and senior residents in an extension of the traditional “see one, do one, teach one” paradigm of surgical education. This finding could potentially lend support to allocating residents into teams with senior and junior resident components although it needs further formal study.
Residents subjectively valued the addition of a surgical skills lab based on a cadaveric model highly relative to other resources, especially in gaining surgical skills. Residents perceived the lab to have value for learning and practicing the basics of arthroscopy and they perceived the skills practiced in the lab to translate to the OR through increased confidence, speed and efficiency and participation in the OR. These benefits are very important given the increasing pressure on academic training programs to be efficient and more productive in the operating room. These outside pressures can result in less time for resident participation and teaching in the formal operating room setting. If it is true that practice in the lab translates to more efficient performance in the OR, then patients also stand to benefit through decreased anesthesia and OR time and perhaps through decreased risk of iatrogenic injury.
O’Neill reported that over half of all orthopaedic training programs had cadaveric wet labs in 20023. The provision of the opportunity for repetitive practice of arthroscopic skills over the course of an orthopaedic residency is appealing as it has been shown that procedural skills are not retained without repetitive exposure, suggesting that repetition and multiple training episodes are preferable4. Surveys of teaching faculty at training programs also suggest numerous exposures are needed for trainees to gain proficiency in common orthopaedic arthroscopic procedures3. A significant learning curve exists with exposure to new arthroscopic procedures, even for practicing surgeons, suggesting that repetitive practice is essential for residents where all aspects of arthroscopy are new5. (Snow and Stanish KSSTA 2010) A skills lab is a way to enable residents to practice surgical skills without the time constraints associated with the OR. Residents can use the lab at their convenience and can repeat a procedure as often as desired.
The cost-benefit ratio of skills lab utilization in a training program has not been evaluated. Initial development and start-up, maintenance, cadaveric specimen purchase and other costs are incurred. However, there is literature to suggest that simulation training can transfer to increased competency and skill in the operating room. In a 2008 study of the effect of laboratory-based simulator training on resident ability to perform knee diagnostic arthroscopy, Howells et al. demonstrated improved skills in trainees that underwent repetitive instruction using a bench-top knee simulator4. Transfer of skills after training using a cadaveric model has not been evaluated to our knowledge. However, use of cadaveric specimens is common and a preferred method of learning surgical skills in orthopaedics. Vitale et al. surveyed more than 2400 members of the American Academy of Orthopaedic Surgeons and found that practice on cadaveric specimens ranked third relative to sports medicine fellowship and hands-on courses in importance for learning arthroscopic rotator cuff repair6. In addition, skills assessment systems are being developed for use in simulated learning situations7.
Our survey results show that the skills lab was highly regarded by our residents for learning arthroscopic techniques. Substantial benefit was noted for becoming familiar with equipment, instruments, procedures, anatomy and especially with practicing the 3-dimensional aspect of arthroscopy. Our residents felt that skills lab sessions resulted in increased confidence, efficiency and participation in the operating room.
Teaching in the clinic and in didactic settings will continue to have places in orthopaedic education. Trainees in our program still valued teaching in the clinic setting highly. This is an important finding in light of reduced work hours and increasing surgical burdens on teaching programs. As training programs move residents to the operating room for a larger majority of their weekly schedule, the educational benefit of seeing outpatients in the clinic setting may be overlooked. Our residency program has six residents per year, and residents spend varying amounts of time in outpatient clinics and the operating room depending on which of the nine different services they are rotating through. The formal educational curriculum with didactic lectures, case-based conferences, morbidity and mortality, fracture conference and grand rounds are incorporated into two 90-minute conference sessions during the week. Each subspecialty team additionally has team conferences with subspecialty education and case review components.
There are several limitations to this study. We collected information from only one orthopaedic residency program, thus our conclusions may not be generalizable to other residency programs. Also, our sample size was small and the data available from our study is limited and not amenable to detailed statistical analysis. Small sample size may limit the power required to detect differences between different PGY levels. Whereas PGY1s may rank cadaver-based training higher due to their limited experience with “real world” arthroscopy, PGY5s may consider cadaver-based training unrealistic compared to their experiences.
In conclusion, orthopaedic trainees highly value operating room experience as the primary resource for education during residency. Orthopaedic trainees have found the addition of a surgical skills training lab for teaching arthroscopic skills a significant benefit to both their overall education and to surgical skills training.
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