HARVARD COMBINED ORTHOPAEDIC RESIDENCY PROGRAM
James H. Herndon, MD, MBA
PROGRAM DIRECTOR, HARVARD COMBINED ORTHOPAEDIC RESIDENCY PROGRAM

Chairman's Corner: Introduction

We had a very successful match again this year. As you recall we are in the midst of expanding our program from 10 to 12 residents per year. (This increases our total number of residents from 50 to 60.) With this recent match completed we will have 12 residents through the PGY 4 year beginning July 1, 2006. The full conversion to 60 residents will occur after the next match in July, 2007. This July with 12 residents in the PGY 4 year we will begin our two-month research rotation (the goals and objectives I described to you in last year’s Director’s Corner). Every two months two residents will rotate on the service and will have lectures, seminars, journal clubs, on-line and reading requirements, as well as the opportunity to complete their thesis work

The Second Annual OREF New England Research Symposium was held at the Massachusetts General Hospital on May 5, 2006, which was hosted by Dempsey Springfield, M.D. and myself. Fifteen papers were presented and three awards were given. Residents from our program who presented terrific papers included: Andrew Jawa, MD (“Extra-articular distal-third diaphyseal fractures of the humerus: Comparison of Functional Bracing and Plate Fixation”), Alexander Sah, MD, (“Survival of the prosthesis beyond the patient: unicompartmental knee arthroplasty in octogenarians”), and Nina Shervin, MD, (“Hospital and surgeon procedure volume with patient-centered outcomes of orthopaedic surgical procedures: a systematic review of the literature”). The judges were: David Ayers, MD (University of Massachusetts), Charles Cassidy, MD (Tufts), James Heckman, MD (Editor, Journal of Bone and Joint Surgery), Paul Hecht, MD (Dartmouth), Dempsey Springfield, MD (Harvard), Richard Terek (Brown) and myself. The keynote address was given by Kevin Bozic, MD, MBA entitled “Disruptive Innovations in Orthopaedics.” Kevin’s talk was unique and outstanding. I know he stimulated everyone into new ways of thinking about introducing new technologies and our very dysfunctional health care system.

We continue to assess our residents as required by the ACGME in the six Core Competencies. I thought you might be interested to see how we are doing as a residency program measuring the outcomes of these educational efforts. An accurate measurement of the effectiveness or outcomes of our teaching program is the eventual goal for each competency required by the ACGME. This is a list of our methods to evaluate the residents in each of the six Core Competencies: (those with * are measurement tools)

As you can see we need additional tools (as do other residency programs) to measure the effectiveness of our teaching success in these six categories. This is an evolving process and in order to meet accreditation requirements each residency program must demonstrate how they are progressing in the implementation of tools to measure outcomes in each of the six Core Competencies. A great deal of work is still required. All residency programs are beginning to learn from each other and we hope the ACGME will begin to provide accurate measurement methods.

The Saturday breakfast program with the residency director continues and remains successful. The following items have been discussed at these breakfast meetings this academic year:

  1. Leadership issues
  2. Review of current revenues / expenses of Orthopaedic practices (Margin of Operations)
  3. New ICD- 9 / CPT codes
  4. Orthopaedic organizations – Alphabet Soup
  5. Review of HCORP graduates’ performance on ABOS exams
  6. Medicare payment changes
  7. Pay for Performance / Gainsharing Initiatives
  8. How to Start a Practice
  9. Financial Planning / Basics
  10. Initial Employment Contract - What to Look for and What to Avoid


This year, I have some additional time available, since I no longer have the department chairman’s responsibilities and I have voluntarily discontinued operating, (however, I still see patients at the MGH and BWH and refer those patients needing surgery to our colleagues). I have been reviewing our residents and our residency program’s past performance regarding work hours, success on Board examinations, success on the Orthopaedic In-Training Examinations (OITE) and the surgical experience of our residents before and after the 80 hour work rule.

COMPLIANCE WITH WORK HOUR RULES

Our residents are burdened with a great deal of paperwork today just as you are experiencing in your own practices. Residents must now log their daily work hours electronically for two months out of four during the year. The data is reported directly to Partners Healthcare System and then to the ACGME as well. The following is a brief analysis of our residents’ work hours in the last two months:

  1. There were very few instances where the residents worked more than 80 hours per week. We were in compliance 98% of the time. There was only one instance where the resident was on call more than every third night and we were essentially 99% in compliance.


  2. As we adjust to these new time demands and constraints on our residents we are having difficulty adjusting in three areas:
    • The first is one day off in seven averaged over four weeks. We had exceptions to this in all five years of our residency program; the majority being in the PGY 1 year. We were in compliance only 76% of the time.
    • The second is difficulty in compliance with work > 24 hours. We had a significant number of instances were residents worked more than 24 hours straight. By far the majority of these were in the PGY 1 years.
    • A significant difficulty –which is a problem for all surgical fields - is with the requirement of at least 10 hours off between shifts. A number of instances occurred where residents did not have 10 hours off between shifts. These exceptions occurred throughout each year in the residency program. It has been almost impossible to adjust resident coverage when delays in the operating room force elective surgery to be started in the evening. Though we have a very large total number of residents, there are only a few on each service - spread too thin for residents on other services to cover an elective case starting early or late in the evening. There are no “extra” residents - only those residents on the service and, of course, they are the ones taking care of the patients and obviously want to participate in their surgery. As a consequence residents often only get five to eight hours off before returning to work the next day.
The Executive Committee and faculty as well as the residents are adjusting and adapting to these time constraints and improvement has already been seen. I am optimistic that we will be in full compliance before our next Residency Review site visit.

EXPERIENCE OF BOARD EXAMS PART I AND II AND ORTHOPAEDIC IN-TRAINING EXAM (OITE)

Over the last 16 years our residents have performed very well on Part I and Part II of the American Board of Orthopaedic Surgery examinations. However, only four times during this 16 years did 100% of our residents pass Part I on the first attempt and on only five occasions pass Part II on the first attempt. Our residents’ performances on the OITE have changed over the last 31 years. Since 1989 there has been a steady improvement in our percentile position (compared to other residencies) in the examination. Residents now routinely score in the upper two deciles. However, on careful analysis of each specialty, reviewing each class and graduating classes, improvements are needed. For example, in-training exam scores increased in Pediatrics, Foot & Ankle, Sports and Shoulder during this period of time, but no significant change occurred in Trauma and Medical Issues. Surprisingly, there has been a slight fall in the overall performance of our residents on Hip/Knee, Spine, Hand, Orthopaedic Disease, Rehabilitation and Basic Science. In view of this data, the Executive Committee and I are having discussions with the faculty and the residents on how we can improve. I have recommended to the Executive Committee and the faculty that an individual on each specialty division take the in-training examination yearly to ensure that our educational program is in sync with what residents are expected to know as determined by other national leaders. Each specialty division chief will also be given his/her specialty data, including scores on the ABOS exams and OITE exams. They will be able to use the information to modify and change their teaching conferences and Core Curriculum programs.

SURGICAL EXPERIENCE

I am monitoring the surgical experience of our residents, in terms of volume and distribution of surgical cases and their operating room experience as surgeon or assistant. There’s no doubt that residents have little independence today compared with 10 years ago because of the Medicare and ACGME regulations - supervision is mandatory. It is very important that without an extra six months of training as a chief resident that our program meet the needs of our residents in terms of providing them with the clinical and scientific educational material, conferences, patient diversity and surgical experiences that will allow them to be independent practitioners when they graduate. Faculty will have to continue to meet challenges (as do other faculties) on how to improve the surgical experience of residents and most importantly how to measure residents’ performances regarding the six Core Competencies.

I have analyzed the surgical case volume of our graduating residents comparing the graduates in 1999 to the graduates in 2004. In 1999 we had no 80-hour work-week rule limitations. The 80-hour work rules when into effect on July 1, 2003 and, although the 2004 graduates were not completely under the new guidelines, they did function for one year with the work hour’s restrictions. In addition we have made many changes in the program such as Grand Rounds and the Core Curriculum occupying five hours every Wednesday morning. Conference schedules have increased because of the increased number of specialty services and the residents are expected to see outpatients at least one half if not one full day in clinics or offices. With these changes and the work hour restrictions we have seen a 27% increase in the volume of surgery recorded by our residents in 2004 versus 1999. When comparing our residents’ surgical experience to the mean surgical experience of all residents in the United States (according to the Residents Review Committee in 1999) we were 17% lower in terms of total number of surgical cases. In 2004 with our significant increase in surgical volume we were only 10% lower than the mean national average. This is well within range of appropriate surgical experience for residents; interestingly there was also a significant increase in the average number of cases done nationally in 2004 compared to 1999.

In conclusion there are some issues that I think are important for the future of our orthopaedic residency program:

  1. Accurate and effective tools are needed to measure the outcomes of our education and training program in the six core competencies for all residents.


  2. Careful documentation of the residents’ surgical cases, especially regarding whether they performed a major portion of a case or were merely assistants. It is important because program directors are increasingly being asked to verify that the resident is adequately trained to do procedures that are often itemized in documents sent to the program director. Obviously, with the public and payers demanding increasing transparency of health care regarding errors, quality, costs, and other factors, so also will be the transparency of residents’ performance, training and experience. There appears to be a general movement toward having the program directors determine the competency of a graduating resident regarding certain surgical procedures.


  3. We will see increased use of simulation as a surgical educational and assessment tool.


  4. Work hours limitations will definitely continue to be enforced and we will be required to adhere to them. Today it is law only in the State of New York, but currently Congress is considering legislation to make the work hour limitations law throughout the United States. More importantly there are studies that demonstrate an increased error rate when ordering medications if someone has worked for a straight sixteen hours. I think that we may see a further reduction in the actual number of hours residents are allowed to work each day in the future.


  5. Teaching goals and objectives are necessary as well as a curriculum for each of the specialties’ fellowships similar to the residency program. These requirements are increasingly being stressed by the Residency Review Committee and the ACGME. Residents are considered more as students and less as providers of care by accreditation bodies. However, Medicare continues to consider the residents as service providers and, of course, pay their salaries through Part A dollars for their services. There may be movements that Medicare to pay only for patient care provided by the residents and not for any educational conferences or time away from patient care for various reasons.


  6. With the increasing number of faculty at each hospital and clinical care growth expected to continue there will not be enough residents to cover every attending and for every surgical case. There will have to be future discussions about service and education, teachers and non-teachers - all very difficult issues.


  7. The very important and yet poorly understood and poorly defined relationships of the residents with fellows, with physicians’ assistants and with nurse clinicians. There is some movement toward having fellowship programs overseen by the residency program director who is becoming the de facto education officer of a department.

Awards

Two of our residents, John Kwon and Nick Avallone were nominated by the Harvard Medical School Class of 2006 for their excellence in teaching. Congratulations to both John and Nick for receiving these outstanding recognitions by Harvard Medical students.

Additional awards were received by: Andy Jawa and Nick Avallone. Andy received the Best paper at the OTA and re-presented at AAOS on Trauma Specialty Day. The title of the paper was “Distal third extra-articular humeral shaft fractures: treatment with bracing v. plating”. Nick was elected to AOA as an alumnus from UMDNJ - Robert Wood Johnson Medical School. The description of the award is as follows: “This honor is in recognition of your demonstrated commitment to scholarly excellence, continued achievement and excellence in medical education.” Also, Nick received a Partners-in-Excellence Award in December 2005 for service at BWH during his time as Administrative Chief Resident.

The Barrett Family Research Awards were won by Dr. Susan Jordan for Basic Science and Dr. Nicolas Avallone for Clinical Research. The Marmor Award for the overall best OITE average score was awarded to Dr. Benjamin Bengs.

The Combined Orthopaedic Residency Program
PGY-2 Orthopaedic Residents
2006 - 2007


The Harvard Combined Orthopaedic Residency Program
Orthopaedic PGY 1 residents
Starting June 19, 2006





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