Pilot Study for an Orthopedic Surgical Training Laboratory for Basic Motor Skills

Discussion

The importance of surgical skill development in resident education is emphasized in the ACGME Core Competencies.²³ The ACGME instructed all programs to require residents to gain competency in 6 areas: patient care, interpersonal and communication skills, medical knowledge, professionalism, practice-based learning and systems-based practice. Although many surgeon educators and residents are focused on these 6 Core Competencies, current standards do not require surgical skills laboratory training and simply require residents to log cases into the ACGME website. Minimal case number recommendations are in place for graduating senior residents, but these numbers are based on averages with no strong scientific basis.

Although sweeping changes in orthopedic residency training went into effect July 1, 2013, this system remains untested and may offer room for improvement. One change is the restructuring of the PGY-1 internship. A basic surgical skills curriculum must include goals, objectives, and assessment metrics; skills used in the initial management of injured patients, including splinting, casting, application of traction devices, and other types of immobilization; and basic operative skills, including soft-tissue management, suturing, bone management, arthroscopy, fluoroscopy, and use of basic orthopedic equipment.²¹

Orthopedic program directors and residents were recently surveyed regarding the current state of orthopedic motor skills training.²⁴ Three key findings deserve emphasis: There is a lack of objective criteria for evaluating resident performance in the skills laboratory; most program directors who have a laboratory do not understand the associated costs; and the most significant issue for program directors is the financial challenge of operating a motor skills laboratory. The survey findings strongly suggest that proposed changes in skills training should be accompanied by careful cost analysis before widespread implementation.

Although various online demonstrations of entire surgeries are available, as are textbooks describing a generalized approach to musculoskeletal surgery, we assume that, as laid out in the Core Competencies, residents are fine-tuning their surgical skills by actively participating in operating rooms under direct observation of attending physicians. To our knowledge, however, there are no data regarding how often this happens in the operative setting, where volume and efficiency are becoming increasingly scrutinized. There has been much concern over how hour restrictions will affect residents’ total operative experience.^25,26 Finally, we have no means to objectively evaluate residents’ surgical skills on graduation.

Other programs have implemented surgical skill simulators, but an orthopedics-specific surgical skills laboratory, to our knowledge, has been discussed in only 1 study.²¹ Results from randomized controlled trials reported in the general surgery literature have proved simulation-based training leads to detectable benefits for learners in clinical settings.^27-29 Over the past decade, some alternative surgical skills training methods have been adopted in orthopedic surgery as well. These methods include hands-on training in specifically designed surgical skills laboratories using cadaver models or synthetic bones; software tools; and computerized simulators. In recent years, numerous studies reported in the orthopedic literature have examined arthroscopic simulators in residency training.^18-20,30-34 However, these studies are arguably more specific to sports subspecialties and thus more pertinent to upper-level trainees.

Our study results showed that surgical skills laboratory training should be a required aspect of our residents’ training. Although less of a dramatic improvement was noted in the written examination component of the laboratory, the overall knowledge base improved (Table 3). This was especially evident at the PGY-1 level, where written examination scores increased from a presession median of 80% to a postsession median of 85%. A larger degree of improvement was found with the ankle fracture model, and there was statistical improvement at all training levels, from PGY-1 to PGY-3. Previous work has shown that intensive laboratory-based training can be effective, particularly for first-year residents. Sonnadara and colleagues³⁵ demonstrated that a 30-day intensive surgical skills course effectively helped first-year orthopedic residents develop targeted basic surgical skills. In a follow-up study, Sonnadara and colleagues³⁶ demonstrated that a surgical skills course completed at the beginning of a residency was effective in teaching targeted technical skills, and that skills taught in this manner can have excellent retention rates.

There are limitations inherent in our skills course. The κ agreement in the ankle fracture model was low before and after administration, which we attribute to 1 observer outlier. This could be amended by removing outliers and further objectifying and simplifying the scoring system (A–F). Right now, we do not have enough data to determine whether the scores actually improve significantly through the training years or whether they will correlate with operating room experience. Our study had no control. For future investigations, we are considering having general orthopedic surgeons from the community perform the same scenarios and be graded with the same checklists as a control. Implementation, however, may be a challenge. Both our written examination and our ankle fracture model checklist have not been validated—this is one of our next steps. The point system used to score the ankle fracture model was subjectively developed and would benefit from further standardization before drawing conclusions about true validity.