For the resident, the surgical residency is physically, emotionally, and intellectually demanding, requiring longitudinally concentrated effort. Although education of orthopedic surgeons necessarily occurs within the context of the health care delivery system, vital lessons also are taught in laboratories, skill stations, and surgical simulators. Before practice-based learning can take place, residents must gain experience and demonstrate growth in surgical skills, including decision-making and technical skills. These skill sets are difficult to systematically teach and objectively analyze.
The most effective way to teach and assess a resident’s knowledge of musculoskeletal medicine remains unclear at this point. Much of the current literature addresses the issue at the medical student level.1-7 Some studies have shown the effectiveness of surgical training programs, both cadaveric and computer-based simulators, in teaching various surgical skill sets.8-14 The orthopedic literature has seen a boom in surgical simulators aimed at the upper-level resident. Many of the topics involve use of arthroscopic simulators.15-19 Evidence suggests that simulators can discriminate between novice and expert users, but discrimination between novice and intermediate trainees in surgical education should be paramount.20
The American Board of Orthopaedic Surgery (ABOS) and the orthopedic Residency Review Committee (RRC) recommended new requirements for structured motor skills training in basic orthopedic surgery education,21 which were approved by the Accreditation Council for Graduate Medical Education (ACGME) board of directors and went into effect on July 1, 2013. In response to the new ACGME guidelines, our institution created a skills laboratory devoted to surgical simulation. Our focus in implementing this surgical skills simulation was junior-level, specifically postgraduate year 1 to 3 (PGY-1 to PGY-3), orthopedic residents. Our first goal was to set up a series of surgical training stations to educate junior-level residents in 4 core areas: handling and comfort with basic power equipment, casting/splinting, suturing, and surgical instrument identification. A secondary goal was to objectively evaluate the residents through written examinations (presession–postsession) and a novel ankle fracture model (pre–post).
Materials and Methods
Institutional review board approval was obtained before beginning the investigation.
Written Examination
We created a multiple-choice 25-question written examination (Appendix) and administered it to 11 junior residents before and after they participated in the training. This examination assessed their knowledge base of basic orthopedic tenets, including basic bone healing, basic fracture repair (Arbeitsgemeinschaft für Osteosynthesefragen [AO] principles22), suturing, surgical instrument identification, casting/splinting, and elementary implant-design rationale.
Evaluator Scorecard
We created an evaluation scorecard (Figure 1) and had 2 faculty members and 2 senior-level residents complete it independently. Junior residents were evaluated on a sawbones lateral malleolar ankle fracture model at 2 time points. As with the written examinations, the junior residents completed the fracture model both before and immediately after the multiple skill sessions. Each of the 15 data points was scored from 1 to 4, for a total of 60 points.
Facility for Surgical Training Session
Our Clinical Skills Education and Assessment Center houses small-group interactive laboratories for administration, debriefing, and assessment of simulations with the latest in audiovisual equipment. Five stations were created: hands-on introduction to surgical power equipment using sawbones, wood, and polyvinylchloride (PVC) pipe; hands-on introduction to casting and splinting; hands-on introduction to suturing; hands-on interaction with surgical scrub technician assisting with instrument identification; and didactic PowerPoint (Microsoft, Redmond, Washington) presentation focusing on core trauma competencies, basic orthopedic design rationale, and basic bone biology.
Development of Surgical Skills Training Session
Multiple faculty members and senior-level residents collaborated to create the skill stations (Figure 2), which were designed based on ACGME recommendations and on weaknesses our program had seen in junior-level residents. We devoted an afternoon to this session, excusing our program’s junior residents from clinical responsibilities. Four PGY-1, 5 PGY-2, and 2 PGY-3 residents participated. (Four of our 15 junior residents were unable to attend because of clinical responsibilities.) The afternoon started by dividing the 11 junior residents into 2 groups. Before the session, while one group performed the ankle fracture model and was being evaluated, the other took the written examination. This closely timed portion was allotted only 20 minutes. Then residents were divided into 5 groups of 2 or 3 and were rotated through all 5 stations. Forty minutes were allotted for each station. Residents were not evaluated during this portion. The stations were intended solely for education, and each station was staffed by a faculty member and/or senior-level resident.
Cordless reciprocating saws and drills were purchased to introduce and refine junior residents’ motor skills. Sawbones, 2×4-in sections of wood, and PVC pipe were used in the training. Emphasis was placed on tactile feel and feedback with both sawing and drilling. For the casting and splinting session, we used 4-in fiberglass, 4-in plaster rolls, and cotton soft roll to demonstrate a multitude of common casts and splints (Figure 3). Casts included short- and long-arm casts and short-leg casts. Splinting included coaptation, sugar tong, and ulnar gutter splints for the upper extremity and a short-leg posterior splint for the lower extremity.
