To the Editor:

Small programs usually have to send residents off-site, most commonly for pediatric orthopaedics, multi-systems trauma, or oncology. If one or two residents are off site and one is on vacation and/or at meetings, how do five or six total residents comply with duty hour requirements, graduated responsibility and critical mass for robust didactics? If Dr. Lincoski's program is as good as she says itis, my opinion is that it would be better with three residents per year.

Michael Simon, MD

To The Editor:

In Dr. Simon’s article “Lessons From Our Medical Colleagues: Proposals to Improve Orthopedic Graduate Medical Education” (1), he brings up many fine points based on his observations of other residency programs. The observations on interactions of fellows with residents are well founded, as is his perspective on the unique and growing responsibilities of program directors. I must, however, disagree with his last point. He states, “…even a two-resident-per-year residency program in orthopedic surgery cannot educate residents adequately.”

As a resident in a two- resident-per-year program I feel that he is generalizing unfairly. Small programs can and do meet the educational standards for orthopedic training and many excel in doing so. At our institution we provide superior clinical education of residents, with residents gaining an early operative exposure; as such our residents graduate with a higher than average number of cases per resident. We have a full complement of subspecialty staff that routinely participates in resident education (except for the recent departure or our Musculoskeletal Oncologist). In the past two years we have scored above the 95th percentile on the annual in-service examination. But most importantly a small program such as ours allows individualized education both at the bedside and at the operating room table.

Our program is based on a preceptorship model with generous one-on- one contact with an attending in a subspecialty for 3-month rotations. This allows the resident to slowly gain autonomy under direct supervision of an attending subspecialist. Unlike larger programs, where residents often feel the need to subspecialize to gain more experience, many of our residents are comfortable going directly to private practice. While there are some clear benefits to larger programs, smaller ones by no means are incomplete or lacking in their educational experience simply based on resident number. Programs such as ours can be competitive and also serve as a model for clinical education.

Sincerely,

Chris Lincoski M.D. Orthopedic Resident Geisinger Medical Center, Danville PA

Reference: 1. Simon MA. Lessons From Our Medical Colleagues: Proposals to Improve Orthopaedic Graduate Medical Education. J Bone Joint Surg. 2004; 86:2073- 6.