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Dr. Markku Nousiainen (left), director of the orthopaedic residency program, with Dr. Sebastian Tomescu

A pioneering program for orthopaedic residents measured by skills, not time 

Would you let a pilot fly a jumbo jet without first checking her technical skills? Probably not.

For that matter, what about allowing an orthopaedic surgeon to perform a knee replacement after he completes just a written exam? Not for much longer.

The Competency Based Curriculum in the Division of Orthopaedics Residency training program at the University of Toronto (U of T) is the only program in Canada that's designed similar to an airline pilot's training. It ensures residents are competent on simulators before treating patients, evaluates them on necessary skills as they go and ensures that they meet all objectives of training at the end of their curriculum. The program was designed five years ago by a team of Sunnybrook and University of Toronto surgeons and implemented as a pilot with a grant from the Ontario Ministry of Health and Long-Term Care. It's been gaining worldwide attention from medical educators.

"Typical residency training is time-based or 'tea-steeped,'" says Dr. Markku Nousiainen, an orthopaedic surgeon at Sunnybrook and director of the orthopaedic residency program. "If you do five years of training and then pass an exam,
you are deemed to be capable of practising independently."

That came as a shock to Dr. Sebastian Tomescu. "In medical school, I was surprised to learn that your exam is just in an oral and written format. No one is checking to ensure that you are a skilled surgeon. I thought there'd be a technical exam at the end."

When Dr. Tomescu was accepted into U of T's orthopaedic residency program, he learned of a pilot program that would be quite different than traditional training. "It would be competency-based. I could spend as little or as long on rotations and skills as I wanted or needed, then be assessed," he says. "And at the end of it, I would know that I was competent in the necessary skills."

He agreed to be part of the pilot. First up: a surgical skills "boot camp" in the simulation lab.

"The boot camp brings everyone up to speed," Dr. Tomescu says of the month-long course he now instructs. "It teaches all the little things that are important: how to properly put on gloves, gown and mask, and how to correctly scrub in."

Then there are the basic orthopaedic skills: anatomy, how to treat simple fractures, how to cut bone and drill holes. The residents become familiar with the instruments and the proper techniques for using them, all in the comfort of the simulation lab. After boot camp, they begin their rotations in the hospital. Dr. Nousiainen recalls the first time he was asked to suture on a patient. It didn't go quite as he hoped.

14
Orthopaedic residents in competency-based pilot program at University of Toronto

10
Toronto hospitals involved

5
Years spent in a regular stream orthopaedic surgery residency training program

4-5
Average years spent in competency-based residency (depending on how soon the trainees and their supervisors think that they are competent to move on)

21
Modules to complete during competency-based residency

200+
Hours spent in simulation lab


"I had the wrong size of gloves; I didn't even know what size of gloves to use. The blood stopped flowing to my fingers. And I was so afraid of the staff person getting angry at me that I did a terrible job," he says. "You are too worried about the environment you are in. You are trying to impress, so your hands get shaky. If you practise in a low-stress environment first, you can say to yourself, 'Although I'm in a different environment and people are watching, I know I can do this skill.'"

Dr. Tomescu recalls the first time that he was asked to perform in the operating room (OR) after boot camp. "I felt I was capable of doing a lot more than what the surgeon was asking me to do. The senior resident was asked to put the screws in, and I thought, 'I know how to insert those, too!'" he says. "I actually felt good – I felt like I could already do a lot. I was both comfortable and confident."

Dr. Nousiainen says after boot camp, the first-year residents have the skill level of upper-year trainees. "When it comes to their first time in the operating room, they are already ready to go," he says. "To learn those skills in the OR wastes time. When it comes time to assist during a real operation on a live patient, they've already mastered those skills and they can work on becoming more efficient and effective."

Another major difference in the competency-based training program is the constant feedback and evaluation – written tests, verbal exams and evaluations in the skills lab and operating room.

"We also have '360 exams,' where multiple health-care professionals are asked to provide feedback on our performance – the physiotherapists, cast technicians, nurses," Dr. Tomescu says. "There are also assessments of our interactions with the patient and family both before and after their surgery: 'How did you prepare the patient? Did you explain the risks and benefits? Did you answer the patient's questions?'"

The Royal College of Physicians and Surgeons of Canada has mandated that medical education programs become competency-based in the near future, Dr. Nousiainen says.  A move to competency-based training is a move in the right direction for patients and the health-care system, he says.

"If we can produce physicians who are competent in all aspects of becoming a good doctor – technically skilled and also adept at managing health-care resources, good communicators and collaborators, I think we will have more efficient physicians joining the workforce," he says. "They won't waste money on tests, they will know the literature, they will know the best practices and they'll be better communicators with the health-care team. So competency-based training programs that incorporate these should lead to better, more well-rounded doctors."

Dr. Tomescu finished the residency program in four years, rather than the usual five. "There was more focused attention on ensuring we were learning and moving along," he says "And if there was a problem or a challenge, there was remediation right away, and time was allocated to that task, so we could perfect it."

He passed his Royal College exams and is preparing to start a fellowship at Sunnybrook to further his specialty skills.

"I'm ready," he says.


This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.