Reformation of Surgical Education and Training Dr. Douglas Hedden Walter Stirling Andersen Professor and Chair Department of Surgery University of Alberta.

Reformation of Surgical Education and Training

Dr. Douglas HeddenWalter Stirling Andersen

Professor and ChairDepartment of Surgery

University of Alberta

I, Douglas Hedden declare that in the past 3 years:

I have received manufacturer funding from the following companies*: YesMedtronic Canada

I have done consulting work for the following companies*: No

I have done speaking engagements for the following companies*: YessSynthes Spine

I or my family hold individual shares in the following*: None

*pharmaceutical or medical/dental equipment

2

Declaration of Conflict of Interest

Restriction of Resident Duty Hours• Stimulated by Patient Safety• Reduced number of hours in a given week for

education• Must optimize time spent in training• Little appetite to prolong training• Does it improve patient safety?• Does it improve education and lifestyle of

residents?

National Steering Committee – On Resident Duty Hours

• Jason Frank, Kevin Imrie• Some key findings– The relationship between fatigue, medical error and

patient safety is unclear– There is no conclusive data to show that duty hour

restrictions (consecutive) are necessary for patient safety• Complicated and needs to be looked at

comprehensively

Resident Duty Hours Restrictions• No clear evidence that academic

performance is altered either positively or negatively

• There is evidence suggesting suboptimal patient care and educational outcomes in surgery resulting from the restriction of resident duty hours

• Health human resources are affected

Resident Duty Hours Restrictions• Must redesign Residency Training to

maximize educational experiences and to provide safe patient care

Canadian Consensus• Residents have dual roles as care providers and learners• Residents are vital providers in a health care system

that is collectively responsible for 24/7 patient care coverage

• Duty periods of 24 or more consecutive hours without restorative sleep should be avoided

• Efforts to minimize risk and enhance safety are necessary and cannot be undertaken by addressing the resident duty hours alone

Canadian Consensus• Given the substantial variation in resident

training needs, a tailored and rigorous model for resident duty hours and the provision of after-hour care is needed.

Competency Based Medical Education (CBME)

• Most training programs are based on time based rotations

• Promotion is based upon successful completion of time spent on rotation

• Assessment criteria are often not robust• ITER should be based upon Rotation Specific Goals

and Objectives – how complete is that assessment?

CBME• Must define the competencies that an

individual must demonstrate to be considered a surgical specialist

• Must assess that the individual has obtained those competencies

• Must assess that the individual has maintained and further developed and refined those competencies

CanMEDS• Medical Expert– Intrinsic roles• Health Advocate• Collaborator• Communicator• Manager• Scholar• Professional

CanMEDS 2015 FrameworkCompetency Across the Continuum

• Competency milestones within each existing Role– New competency milestones in each existing

Role in training and throughout the entire career– New content – patient safety and

interprofessionalism– Make it easier to teach and assess the CanMEDS

Roles

Milestones• The Royal College defines milestones as the

abilities expected of a physician or trainee at specific points in their development as professionals.

• Educators will be better able to assess the areas where residents require help and identify if the resident is performing adequately

CanMEDS 2015• The abilities will be much more specific and

related to stage of training– Undergraduate Residency

Fellowship/Diploma CPD• The scope of most practices changes with

time • The competencies necessary to practice are

under continuous change

Competency By Design – Time Course

• 2013/2014 – Development of CanMEDS 2015• Pilot Project – Pilot projects with specialty-

specific competency milestones with early adopters – refine the system

• E-Portfolio – personalized, spanning entire practice and including summative portfolios

What Will be the Challenges• Dedicated faculty – much greater

commitment• More frequent and focused assessment• Unknown timelines for completion of

training– Manpower issues– Prolonged training

The Toronto Orthopedic Model (Reznick, Alman)

• Program Directors – Bill Kraemer, Peter Ferguson and Markku Nousiainen

• 21 modules in 3 phases• Residents move at their own pace• Use of simulation• Evaluation based upon MCQ, OSATS, multi-source feedback,

patient assessment and management examination, observed histories and physicals, ward audits,etc.

Funding of Residency Education• Dependent on the Provincial Government– Funds allocated according to a ratio based upon

undergraduate enrollment– Based upon typical times residents spend in

training– Difficult to fund extra years– CBE could lead to both shorter

and longer training times

Funding of Residency Education• Education based upon the concept of

volunteerism is being challenged– Fewer Faculty positions available

• Loss of Industry sponsorship for educational events

Post Residency Training• Fellowship training is the rule not the

exception– Lack of uniformity (Diplomas)– Funding may be difficult– Conflict with residency education– Super Specialists who do not provide the basic

care– Reality of lack of manpower planning

Post Residency Training• If everyone is doing fellowships what are we

doing wrong in residency?– Should be personalizing training• More sub-specialties• Streamed programs