If the title looks familiar, it should. Except
for "déjà vu," it is exactly the
same title that was used in Dr. W.F. Enneking’s Presidential Address
to the American Orthopaedic Association (AOA) in Palm Beach, Florida,
on May 16, 19841. I chose this
title and subject because of my interest and involvement in graduate
medical education in orthopaedic surgery and also to pay homage
to an individual who continues, even in "retirement" at
age seventy-five, to take time to educate orthopaedic residents
with a yearly orthopaedic pathology and oncology course. Throughout
his career, Dr. Enneking has spent numerous hours educating medical
students and residents. For more than forty years, he has taught
a national two-week course for orthopaedic surgery residents as
well as a one-week course for medical students. He used personal
time, in addition to professional and clinical time, to teach medical
students. All of this is in addition to the time that he spent in
weekly didactic sessions with orthopaedic residents and oncology
fellows at the University of Florida. In fact, the sole reason that
I became an orthopaedic oncologist, and one of the reasons that
I became an academic orthopaedic surgeon, is that I was fortunate
enough to attend one of his pathology courses as a resident. The
experience was so inspiring that I took a clinical fellowship with
this master educator the following year.
Some of my concerns in this Presidential Address on graduate medical
education in orthopaedic surgery were expressed by Dr. Enneking
in 1984, and unfortunately these issues have not been
resolved. In my opinion, the quality of graduate orthopaedic education
has continued to deteriorate. The themes that I will address are,
first, the concept of a resident as a student; second, the deplorable present
resident-selection process; third, the weak links in evaluating
resident competence, which present an opportunity for an expanded
role for orthopaedic program directors and the American Board of
Orthopaedic Surgery (ABOS); and, fourth, the roles that the AOA,
the Academic Orthopaedic Society (AOS), the ABOS, the Residency
Review Committee (RRC), and the American Academy of Orthopaedic
Surgeons (AAOS) may play in improving the graduate medical education of
future orthopaedic surgeons.
Orthopaedic graduate medical education is an area where the AOA,
the AAOS, and the ABOS are indirectly involved but are huge stakeholders
in the outcome. It is my hope that the AOA can fulfill its mission
to engage all of the organizations mentioned above to improve the graduate
medical education of our professional offspring, the future orthopaedists.
The identification of a resident as a student or an employee
is an overarching problem that, of course, is not unique to orthopaedic
surgery. Nor is it a new problem—about 100 years ago, when
graduate medical education was first organizing, residents were
paid a stipend by a hospital. Therefore, in spite of the
fact that their activities were supervised by doctors who were not
employed by the hospital, their income and benefits were mostly
funded through a hospital. This duality or paradox continues even
today, with the result that the economic and educational missions
of the important constituents of graduate medical education—the
teachers (doctors), the students (residents), the hospital, and,
most often, the university (medical school)—are not aligned.
The conflict between the mission of providing medical care and that
of providing graduate medical education is the central ambiguity
in the role of the resident. To illustrate this paradox, I recall three
personal anecdotes from the time when I was a resident, from 1967
to 1974.
In 1966, the first resident job action occurred, in Boston. I don’t
recall the reasons, but I am sure that we can guess them: pay below
the poverty level, substandard working conditions such as excessive
work hours, noneducational activities (scut work), and so on. The
result of that job action was the right of residents at
public institutions to organize and, yes, to strike. This decision recognized
medical residents as employees. As a resident at the University
of Michigan, I personally benefited from the job action. As a PGY-1,
in 1967, my salary was $3640; it went to $6600
when I was a PGY-2. Adjusted for inflation, the salary that I received
then is very similar to that received by today’s residents2. A recent court decision now allows
residents at privately owned hospitals to organize. This decision
also recognizes residents as employees, not students.
The second personal episode that brings forth the paradox in
resident education is my football-ticket story. As a freshman at
the University of Michigan, I sat in the end zone. During the next seven
years, I slowly moved to the fifty-yard line. As a senior medical
student, I had the best seats in the stadium, as good as those of
the rich alumni. As soon as I became a resident, I was back in the
end zone. Why? Because now I was an employee of the hospital. So
I sat among the gardeners, janitors, transporters, and noncontributing
alumni.
Lastly, when I came back from Vietnam, I received funds for my education
from the GI bill. However, even the federal government had a difficult
time determining whether we were students or employees. In some federal
districts, the GI bill for education was ruled taxable and in others
it was ruled free from income tax, based on whether the district
deemed the resident to be a student or an employee. Even now, the
Internal Revenue Service is still making rulings concerning the
question of whether medical residents are employees or students.
The ambiguity intensified when the federal government started funding
graduate medical education through the Medicare program. Before
that, insurance companies such as Blue Cross paid hospitals for
resident costs. However, expenses for resident salaries were modest.
The initial Medicare funding was similar to the Blue Cross paradigm.
Medicare paid whatever costs of education that hospitals reported. So,
as you might imagine, resident numbers and expenses skyrocketed.
Where else could you pay such low wages for extremely intelligent
employees, working inordinate numbers of hours and without a job
description, for a highly reimbursable activity? Thus, the more
residents that a hospital had, the better its profit margin. We,
the teachers (doctors), are not blameless. Residents who provide
care extend our clinical practice. Even today, in spite of investigations
by the Health Care Financing Agency (HCFA) concerning fraud and
abuse, and onerous compliance mandates, residents who provide care,
especially in surgery, are huge profit providers. In my opinion,
that is the main reason that there are so many residents. Residents
are very profitable for hospitals and doctors. There will not be
a decrease in the number of residents until they become less profitable.
The federal government reacted to the uncontrollable expenses slowly,
as usual. The HCFA was established. Diagnostic Related Groups (DRGs)
were established in 1984 through 1987, tying the cost of care to
a particular diagnosis and linking funding for graduate medical
education to a formula of direct and indirect medical costs that
only a bureaucrat could design and understand.
In the 1990s, the ascendance of health maintenance organizations
(HMOs) and the Balanced Budget Act of 1997 significantly decreased
reimbursement to hospitals. These two events have made hospitals
act more businesslike, have caused closures and mergers of hospitals, and
have given rise to for-profit hospitals. With the greater focus on
their business, hospitals, by necessity, are more efficient in delivering
patient care, as society has desired.
The number of patients and their throughput in teaching hospitals have
markedly increased, while the number of residents in orthopaedic
surgery has remained relatively unchanged3,4. Now the teaching hospital is almost
an intensive-care unit. Residents are providing more care while
having less time for education. Because much of orthopaedic surgery
is being done on outpatients, residents also provide surgical assistance in
a large volume of cases. Now residents are even more valuable as
providers of care.
I believe that we are currently in a crisis over the
dual role of residents, particularly orthopaedic surgery residents,
who are very profitable providers of care. Hospitals are even more
efficient businesses than in the past, but they are businesses nonetheless. Their
already compromised interest and ability in the educational enterprise
are diminishing. Look at your residents’ contracts. They
are more and more restrictive regarding such things as drug-testing
and conflict of interest. Residents are treated as employees or
trainees. Education costs money and is not profitable. As Enneking
stated, "The difference between training and education
is a fundamental conceptual one when dealing with the issues of
quality."1 He often quoted
his orthopaedic godfather, Howard Hatcher, as saying, "You
train dogs and educate men." Enneking went on to say, "The
concept of training is one of repetitive practice until
a skill is mastered, while an educational experience embraces the observational
outcome of applying rational principles based on scientific concepts."1 Our residents have become surgical
assistants. They are proficient in surgical techniques, but they
are deficient in applying judgment and rational principles based
on scientific knowledge.
How can we effect change? As a small component of the entire graduate
medical education enterprise, we may not have much influence on
the ultimate outcome of the struggle concerning the financing of
graduate medical education. My solution is to give the Medicare
funding or other funds to the educational institutions—universities,
educational consortiums, and the like—and to take the money away
from hospitals. In fact, it is my belief that, if there is a continued
decrease in federal funding for residents, hospitals will voluntarily
shut down residency programs, as happened in Cleveland. Hospitals
have little interest in education, especially if it becomes unprofitable.
Education is the mission of educational institutions and providing
care is the mission of hospitals, as is apparent from a review of
the mission statements of the respective institutions. The funding
and the mission need to be aligned while this drama is
played out across the political agenda.
My suggestion is for orthopaedic surgeons involved in graduate medical
education to wipe out the words "employee" and,
especially, "training" from their vocabulary.
I propose substituting the word "education" every time
that you are about to say "training."
A training program is characterized as a hospital-based program,
where a resident evaluates patients for same-day surgery, talks
to the attending physician about the surgical indications at the
scrub sink, assists in or performs the surgical procedure, and manages
inpatients. The diagnosis has been made in the faculty office or
the clinic, and the treatment has been prescribed prior to the resident’s contact
with the patient. The patient is discharged quickly, and follow-up
occurs in the faculty or attending physician’s office.
In a training program, residents are often sent to courses in order
to acquire basic knowledge and to obtain clinical-judgment or problem-solving
ability. However, these well-trained residents don’t see
the relevance or connection to patient care. They are smart and
are able to memorize information that will allow them to pass the
Part-I written examination of the certification process, but when
about 10% of these residents fail the oral examination, they
are bewildered5. They don’t
even understand why they failed. They don’t realize how
all of the patients whom they saw and operated on in their residency
got to the operating room. They have superb cognitive and technical
skills, but they lack clinical judgment, communication skills, and,
in some instances, ethics. In this training environment, research
as an educational component is usually absent, and conferences and
lectures on basic knowledge are given by house staff or nonorthopaedic
surgeons. When conflicts between educational activities and the
provision of care arise, service always comes first.
We, as leaders of the specialty and of the educational programs,
must stop and reverse this seemingly irreversible erosion of the
educational mission—not only because it is the moral and ethical
thing to do, but out of self-interest. If our specialty is to survive,
we must educate physicians who will have the interest and the ability
to engage in lifelong learning.
Our residents are students, and we are their teachers. What are the
characteristics of a quality educational program? Just think about
your undergraduate or medical school experience. There were libraries,
conference rooms (lecture halls), laboratories, didactic lectures,
computers, seminars, and so on. Does your graduate educational program
have these characteristics? Do your residents have dedicated didactic
conference times, conference rooms, computers, and laboratory and
research time? Do they even have a place to put their books, papers,
or clothes? As a past specialist site visitor for the orthopaedic
surgery RRC, I found it remarkable that some programs don’t
even have a place for residents to hang their coats, let alone for
the attributes of learning that I just mentioned. No wonder that
residents become trainees or employees and not students.
All of the attributes of a quality graduate educational program, including
libraries, conference rooms, laboratories, space, equipment, computers,
and, most importantly, faculty and resident time, cost money. In
this era of increased pressure to care for more and more patients
who are sicker and sicker, and with less revenue to the hospitals,
the provision of care has overwhelmed our educational mandate and mission.
I have heard many leaders complain that the attributes of a quality
graduate educational program and the new requirements of the ABOS
and RRC increase costs. My response is twofold. First, orthopaedic
residents still are profitable. More importantly, education is expensive.
If you don’t want to pay for it or if you don’t
want the honor of educating future orthopaedic surgeons, get out
of education. Drop your residency program and/or go into
private practice. You will certainly be more efficient and productive
in patient care. We should not profit from our students. Residents
are not trainees, employees, surgical assistants, physician extenders, or
professional assistants. Residents are not for "covering" operative
cases, clinics, and emergency rooms. They are students, like postdoctoral
candidates. Resident education is not the by-product of patient
care. It requires time away from clinical affairs for students and
teachers. Time is expensive!
The vast majority of medical students are well-motivated, of
high intellect, and physically able to be orthopaedic surgeons.
Among this highly selected group of individuals, orthopaedic surgery has
the most competitive ratio of American medical school graduates
to PGY-1 positions in the National Resident Matching Program—1.58
to 1.00 in the year 20006. The
competition for these PGY-1 positions is so fierce that the lowest
number of applications per student in the last five years, by my
yearly survey, is about twenty. I have met students who have applied
to more than eighty residency programs. Thus, almost all orthopaedic
surgery residency programs have about 100 applications from American medical
school graduates for each position. Why, then, is there concern
that we are educating incompetent orthopaedic surgeons? To say that
we have the best and the brightest is a self-serving, self-congratulatory,
and arrogant assessment. It is a self-propagated myth. If it is
so, why don’t we attract any MDs or PhDs from the medical
scientist programs across the country? And why did an ad hoc Committee
on Resident Selection, sponsored by the AOA, in 1984, find that
one in six resident selections made by program directors was thought
to be inappropriate and that one in twelve was thought to be a serious
mistake?7 Program directors had
indicated that they considered the affective domain to be most important
and that they needed help in evaluating potential candidates in
this area. We now call the affective domain ethics, professionalism, and
communication skills.
Why do approximately 10% of first-time takers of the
written examination of the ABOS fail, and, of those 90% who
do pass, why do 10% fail the oral examination?5 Why does the credentialing committee
of the ABOS need to carefully review approximately 5% of
candidates yearly?8 Why did the
AAOS recently have an ad hoc Committee on Troubled Physicians and
reach the conclusion that these individuals could readily be found
to have been problem residents?9 In
the past three years, questionnaires administered to candidates for
the ABOS oral examination and the oral recertification examination
showed that candidates believed that between 6.3% and 12.2% of
orthopaedic surgeons practicing in their community should not be
certified because of unethical conduct10.
All of the numerous task forces, the Delphi panels of the AOS, and
scholarly works in our specialty have declared that deficits in
the attributes of professionalism, such as integrity, honesty, and
ethics, account for the vast majority of incompetent orthopaedic
surgeons. We do not need any more studies, questionnaires, or symposia
on the subject. We need to take action.
By the time that these residents take their certifying examination, apply
for the oral examination of the ABOS, or apply to the AAOS for membership,
it is too late to take corrective action. I believe that the recertification
process, or the continuing competence movement, will be ineffective because
the processes are too far "downstream." We need
to identify individuals with inadequate attributes of ethics and
professionalism in the selection process or early in the
residency, and, quite frankly, we need to have the ability and the
will to terminate them. Deficits in ethics and professionalism are
not correctable. I do not believe that remedial action will be able
to correct these deficits in residents who are twenty-five to
thirty years old. We may be able to teach ethics to residents, but
we will not be able to make physicians practice ethics. As professionals,
we owe it to our profession and to the public whom we serve.
The selection process is particularly vexing for program directors.
I have not become better at it after twenty-five years, and some
of my younger faculty are better than I am in carrying out the process.
The system that we now have makes the selection process
almost a lottery. Medical students have to make a career decision
by the first half of their junior year, many times even before they
have had any contact with orthopaedic surgeons. In some medical
schools, students have no contact with orthopaedic surgeons until
their senior year. Thus, medical students have little idea about
our specialty and yet are making lifetime decisions. This issue
has been exacerbated by the emphasis on primary care, which is squeezed into
the junior year of medical school.
Medical students apply for clerkships in orthopaedic surgery
in the second half of their junior year, at institutions where they hope
(pray) that they will get a job. A student from a medical school
that sponsors an orthopaedic residency program or a clerk in that
program has the best chance of matching. Then comes the
mass-interview ritual in December and January of the senior year.
To alleviate the situation of 100 applications per position, artificial
barriers are set up. First, there are mass-interview days, during
which scheduling conflicts force the applicants to choose among interview
opportunities. Then, there is a fly-by interview, which gives
the faculty no indication of the ethics and professionalism
of the candidate.
A particularly pervasive strategy of program directors is to
use United States Medical Licensing Examination (USMLE) scores and
Alpha Omega Alpha honor-section status to cut down on the number
of applicants interviewed. The Electronic Residency Application
System (ERAS) makes this screening easier. Program directors at
least will have applicants with high cognitive skills who will pass Part
I of the ABOS examination. Presently, the only objective standard
of the RRC in the evaluation process of accreditation of orthopaedic
surgery residency is a 75% pass rate on the written examination
by first-time takers11. No wonder
we recruit the brightest! But they are not always the best! The
current system does not allow program directors to evaluate attributes
of ethics and professionalism such as integrity, honesty, and empathy.
Cognitive knowledge is the preeminent selection criterion for interviews.
In the present chaos, how can we weed out those who do not have high
professional standards? The candidates for residency cannot and
should not take numerous clerkships around the country. We cannot
go back to the undifferentiated PGY-1 year so that we can see how
the prospective candidates perform in the workplace. We need professional
help in the selection process. The symposium that was jointly sponsored
by the AOS and the AOA in Asheville in 1998, and another symposium
held at the AOS meeting in New Orleans in 1999, did not lead to
an organized action toward improving the selection process. The
AOA should take a leadership role and, with the support of the AAOS, the
AOS, the ABOS, and the RRC, should sponsor a workshop, utilizing
leaders from other professions and from business, on how to interview
and select individuals who have high ethical and professional standards. Program
directors and chairpersons need help, and all of organized orthopaedic
surgery needs to participate! Program directors are not educated
in making personnel decisions and were not chosen for their expertise
in this area. Our profession and the public will benefit from improvement
in the selection process.
Presently, the orthopaedic RRC and the ABOS have little direct impact
in assessing and substantiating the competence of residents. The
RRC accredits programs and therefore has little influence on individual
residents. Furthermore, the RRC has only one objective outcome measure that
evaluates the quality of a residency educational program: performance
on the Part-I (written) component of the ABOS certification examination11. There are no further outcome measures
of the quality of the residency program. The RRC does require periodic
resident evaluations, but, believe it or not, it does not evaluate
the content of the evaluations. It cares only that the evaluations
are done. Although there is presently a strong coordinated
effort between the American Board of Medical Specialties
and the Accreditation Council of Graduate Medical Education (ACGME)
to have regular, systematic evaluations of residency programs that
assess other components of competence, such as communication skills,
ethics, and professionalism, RRCs are really powerless because they evaluate
only the program, not the individual—that is, the resident.
It is the ABOS that, through the certification process, has the
real power over an individual. The RRC can establish more objective
measures of the performance of a program, such as the numbers of
surgical procedures, outpatients, didactic lectures, presentations,
and publications and the amount of laboratory space. However, the
RRCs have no direct influence on the individual resident. More objective
measures of the quality of the educational program will improve
the program, but they may not have a direct impact on the individual.
So, in my opinion, it is up to the ABOS and the program directors
to have a more direct influence on the performance of residents.
Furthermore, the RRC is weakened by the committee-membership
selection process. Presently, the parent organizations of the orthopaedic
RRC are the American Medical Association (AMA), the ABOS, and the AAOS.
Members are appointed by the parent organizations for six years.
Each parent organization selects a single individual whom the RRC
must allow to be a member. The members of the RRC have no
choice. Thus, more than occasionally, the members who are selected
either have self-interest in protecting their own residency program
or represent the parent organization. This weakens the accreditation
process. A recent example of this problem is that allegedly two new
members who had been placed on the plastic surgery RRC were program
directors of residencies that were on probation.
My solution to this problem is twofold. First, strong consideration
should be given to replacing the AMA nominee with an AOS or AOA
nominee. This may be possible because the ACGME is becoming a corporate
entity separate from the AMA. Second, at least as a first step,
there should be more than one nominee from each parent organization
and the RRC should be allowed to select the best-qualified candidate.
A more radical approach, which I don’t necessarily support
but which should be discussed, is to have the ABOS accredit the
residencies. Separation of the accreditation process from the certification
process is a unique American phenomenon. In most if not all advanced
countries, the same organization performs both tasks. Furthermore,
until the 1950s, when the task was voluntarily relinquished to the ACGME,
the ABOS accredited orthopaedic surgery residencies in the United
States12.
Presently, for a resident to sit for the written examination
at the end of his or her residency, the ABOS requires only a yearly report
of the rotation experience of the resident and a signed attestation
that the resident has satisfactorily completed fifty-four months
of an accredited program by the middle of his or her PGY-5 year13. It does not require any minimal performance
in cognitive, technical, or noncognitive areas of competence. Program
directors are not required to provide the ABOS with any objective
measure of competence of the candidate. It is the complete burden
of the program director to decide whether the resident will be competent,
by placing a signature below a single paragraph—a single
global assessment. Most program directors can perform this task,
but some cannot. Program directors are often chosen for other attributes,
but not for skills in the evaluation of personnel. As mentioned
previously in this Address, chairpersons admitted that one of twelve orthopaedic
residents should not have finished the residency program.
I believe that the identification and correction of deficiencies
in competence must take place before the end of the PGY-3 year.
The cost of terminating a residency, if not done before the end
of the PGY-3 year, is too great. Almost all of the information from
the membership committees of the AAOS, the credentialing committee
of the ABOS, and periodic appeals to the ABOS concerning incompetent
or troubled physicians points to problems in the residency. These
deficiencies are almost always known by the program director. Because
the deficiencies almost invariably lie in attributes of professionalism,
the resident passes the ABOS written examination and then, after two
years of practice, is investigated by the credentialing committee
of the ABOS because of poor performance in practice. The oral certification
examination, the membership committee of the AAOS, and the recertification
process can identify incompetent physicians, but the ABOS and the
AAOS are almost powerless to take corrective action unless an individual
commits a felony or loses his or her license. We must do something
earlier to identify, correct, and/or terminate incompetent
residents.
Residents fall into about five categories according to their
performance: outstanding, good or satisfactory, having transitory minor
problems but otherwise good, marginal, and unsuitable14. It is the last two categories that we
must focus on, and we must terminate residents who are in question
early on. The marginal resident is a problem resident who has no
strong qualities, a large number of weak or ambiguous qualities,
and a poor performance. No disasters have occurred, so the evaluators
are reluctant to identify the resident as unsuitable. It is in the
interest of the profession and the public not to allow such a resident
to be certified. The unsuitable resident is easy to identify. Like
the marginal resident, the unsuitable resident may perform poorly
in all components of competence but is also likely to lack integrity and
to be dishonest and/or psychopathic. If these individuals could
be identified in the selection process or in medical school, it
would be helpful for our specialty. These behavioral problems continue
to plague us and are not identified until residency. Unfortunately,
standardized cognitive tests, such as the SAT, the MCAT, the USMLE, and
the ABOS Part I, are still the most valued indicators of performance.
A good test-taker can progress to the oral certification examination
fairly easily.
My remedy for this challenge is for all of the present orthopaedic organizations
to help the program directors not only in selecting appropriate
individuals but also in systematically identifying marginal and
unsatisfactory residents and taking corrective action. All of the
orthopaedic organization specialties—the AOA, the AAOS,
the ABOS, the RRC, and the AOS—should support the workshop
mentioned earlier, and all chairpersons and program directors should
be strongly encouraged to attend. A document that aids program directors
in evaluating, correcting, and terminating residents should be generated
at the workshop and should be given to all program directors and
residents. A second and equally important method to help ameliorate
this important and sometimes painful process of termination is for
the ABOS to actively support program directors in the evaluation process
and to share with them part of the responsibility for the evaluation
of competence during residency. Some of the other medical boards
do share this responsibility, and I think that orthopaedic
surgery should also.
The most important competencies of orthopaedic surgeons are in
patient care, surgical skills, medical knowledge, communication
skills, ethics, and professionalism. The ABOS should require a yearly
evaluation of these skills for each resident, just as it requires
a yearly documentation of their rotations. The ABOS should design,
with professional help, a short annual questionnaire concerning
communication skills, technical skills, and ethical behavior. Starting
next year, the RRC will require an Internet-based operative log
for each resident in every accredited residency program. The ABOS
should work with the RRC to acquire and evaluate these logs.
Also, the ABOS should take on the responsibility of
giving the Orthopaedic In-Training Examination (OITE) in a proctored
and time-limited setting at regional sites. A good, credible examination
must be proctored, secure, time-limited, and psychometrically sound,
and it should be given by the organization that is best equipped
to perform this task. The present in-training examination is inconsistently
proctored, is not necessarily time-limited, is not validated with
regard to content, and is psychometrically questionable. The AAOS,
which, by a quirk of history, has given this examination since 1963,
should give up this responsibility, which is only peripherally related
to its primary mission of postgraduate education. The mission of
the ABOS is evaluation. Most other medical boards, rather than specialty
societies, give the in-training examinations. This would more appropriately
align orthopaedic organizations with their mission. The AAOS is
the continuing-medical-education organization, and the
ABOS is the evaluation organization; both should play to their strengths. Furthermore,
by administering the OITE, the ABOS will gain identity and access
to residents, and it will be able, through the examination
process, to directly determine the curriculum that the certification
process requires. The change will also help to demystify the certification
process.
After the ABOS accumulates and assimilates the yearly evaluation
of residents’ performance in communication skills, technical
skills, ethical behavior, operative experience, and medical knowledge,
it should set some standards for residents to qualify for the Part-I
written examination. I realize that this is an onerous, controversial,
and costly proposal for the program directors and the ABOS, but
unless the program chairs are helped or forced by the ABOS to take
a more systematic role in the evaluation of residents, we will have a
consistent, costly 5% to 10% of our clinicians
who blemish our profession. This proposal could also have significant
implications for program directors and department chairs who are accountable
for graduate medical education. Ultimately, the ABOS could create "report
cards" of the residency programs.
With the above in mind, I will summarize my recommendations to
the orthopaedic community for improving orthopaedic graduate medical
education. First, we should remove the word "training" from
our language in the workplace and substitute the word "education," in
recognition of the fact that residents are students, not employees.
Second, we should support the concept that all funding of resident
education from whatever sources be given to educational institutions, not
to hospitals. Third, the orthopaedic community of five organizations—the
AOA, the AAOS, the AOS, the RRC, and the ABOS—should sponsor
a workshop on the resident-selection process, the evaluation of
resident competence, and the termination of residents. Fourth, evaluating
and ensuring resident competence should have the highest priority.
Fifth, the RRC should increase and broaden the objective measures
of a quality orthopaedic surgery residency and should change its
governance and its process of membership selection. Sixth, the ABOS
should play a much greater role in directly assessing resident competence
by requiring a yearly evaluation of individual residents’ competence and
by administering the OITE. Seventh, the program directors, with
the help of the ABOS, must act more responsibly in terminating the
residencies of individuals who are not competent. Eighth, we need
to take all possible measures to assure the public and our profession
that orthopaedic surgeons are truly educated and competent professionals.
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