How do we educate residents with todays restrictions .... (part I)

“Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods.”

~Albert Einstein

When I was a resident, I really didn't appreciate what my attending had to endure. As we all tend to be, I was selfish in believing that they give me what "I" needed. They were not tending to "my" needs. Most of my thought were on me and my fellow residents. I had a belief that the "man was keepin' a brotha' down." As a system, I though it was built to maintain the status quo. Through our resident union, we even threatened to go on strike. As I progressed through residency and eventually became executive chief resident (otherwise known as the chief resident responsible for paperwork, schedules, and making nice between your residents and everyone else), I had more access to things outside of just my residency and became more aware of the political nature of the academic institution. This really opened my eyes to many things. My opinions of my older attendings changed. I realized that for the 20-30 years, they all had seen changes within the institution, residents and residency requirements, and the politically charged academic system. Most were acutely aware of what techniques were affective in helping a young surgeon to develop certain skills. Each had developed their own way of adapting their training style to accommodate the changes in the incoming generation.

The evolution of an orthopaedic surgeon from medical student to board certified orthopaedic surgeon is extremely complex. Understanding way of educating the surgeon is even more daunting. It requires an understanding of more than just a particular procedure and disease, but also require an understanding of the current generation and must be done within the restrictions of the environment of the time. All of our perceptions are based on our own experiences; so it "makes sense" that our teaching styles would be based on our personality and affected by educators that we found helpful in our own education. We currently are also working around restrictions set by the ACGME, RRC, and other governing bodies. As we try to come up with better and more efficient ways of educating the young surgeon, the resident's perception (in my view) is that we (educators) are not attuned to their needs and we only do things that are beneficial to us (attending staff). I do believe that many of the dedicated educators are more aware of what is needed to become a surgeon than you would probably think. So, how do we adapted to the system and current generation? Well, lets look first at some of the restrictions that are currently in place.

Most allopathic residency programs are under the guidelines created by the ACGME and the RRC. Residency programs must operate under the guise of the American Board of Orthopaedic Surgery, becaue our ultimate goal is to put out board certified orthopaedic surgeons. Most residency programs receive funding from the federal government; therefore, they are also affected by both medicare and medicaid regulations. The one restriction that gets the most publications is the hour restrictions. I may humble opinion, this does make educating a resident a little harder, but not for the reasons many think. The 80 hour restrictions have cause most residencies to react by hiring mid level provides to help or by employing moonlighters to cover shifts/call. For the most part, mid-level provides do not interfere with resident education but should help to make it somewhat more efficient. So, what are some of the restrictions?

ACGME and RRC

Through the ACGME and RRC, residencies are required to do several things for the educational component. These requirements must be uniform. One of the requirements is that there must be 4 hours of didactics that every resident in the program has access to. Service lectures do not count. The question then comes is when to you provide these didactic lectures so that everyone can attend and it does not interfere with the clinical education (surgery or clinic). Each program is also require to have a set number of months in the different specialties. In the near future, I foresee the requirements to even be more strict with require X amount of particular "key" surgical cases.

Medicare and Medicaid

Because hospital receive funding for residencies, there are several restrictions that were developed that directly effect surgical training. HCFA found that because medicare already paid for residents, they should not have to pay for care provided for a patient unless there was an "attending" that was directly involved with the care. With that determination, there went a majority of resident run clinics, and the amount of supervision in surgical residencies greatly increases. As time went along, even stricter rules began to develop with medicaid placing restrictions on the types of encounters that can occur at once. One restriction does not allow a physician to be involved in 2 separate clinical encounters at once without having someone who is completely free of clinical responsibility covering. You can not be both in clinic and in the OR at the same time. You can not run 2 rooms at once (with a resident) with out having someone who has no clinical responsibility covering you (that means they have no clinic or OR). This limits the number of things that can be done at once and by default decreasing the residents access to more exposure to both surgeries and clinical learning opportunities.

Hospital administration

Hospitals to have been effected by the medicare and medicaid regulations causing the hospital itself to create policies to ensure these guidelines are obeyed. Some facilities require the attending surgeon never to leave the operating suite. Dictations must be done within 24 hours. Surgeries can not begin without the attending surgeon being in the room. Many of these policy restrictions are definitely patient protective, but they do interfere with resident education and autonomy. The final thing you always have to keep in mind is that the Administration is always looking at the bottom line, things that interfere with that goal tend to get eliminated.


I could create giant lists of different rules, regulations, and policies that cause interference in the clinical educational component of resident education, but I just want to bring to light some of the restrictions that educator must work around to help educate residents. Next, I will look into the upcoming generation and what limitations educators have secondary to their experiences and perspective.

“Oppressed people cannot remain oppressed forever.”

~Martin Luther King, Jr.