Surgical training throughout the surgical subspecialties has typically followed a so-called apprenticeship model. Experience has been measured on the basis of case log documentation, and competency has been determined by senior mentors. Recently, a paradigm shift in medical education has led to an increasing emphasis on competence—specifically, competence with regard to operative skills, surgical knowledge, professionalism, and the use of assessment tools that can provide credible, accurate, reproducible, and transparent forms of evaluation. Indeed, medical education has become more complex, and the delivery of excellence in education has become more difficult. As an example, restrictions imposed by duty-hour limits and requirements for onsite direct supervision by teachers and mentors has changed the education experience.
Residents-in-training are now required to demonstrate proficiency and knowledge as well as performance in six core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. As of July 1, 2013, the Accreditation Council for Graduate Medical Education (ACGME), in conjunction with the American Board of Orthopaedic Surgery and the Residency Review Committee for Orthopaedic Surgery, has implemented the Orthopaedic Surgery Milestone Project, which includes new requirements for training and the assessment of motor skills during basic orthopaedic education.
The introduction to these and other measures such as simulation is rapidly improving orthopaedic medical education. The article by Samora et al. in the November 2014 issue of JBJS Reviews provides a clear window into the immediate future of graduate medical education in orthopaedics. I strongly encourage you to read this article and to be familiar with its contents. Simply stated, it is the way of the future.
Thomas A. Einhorn, MD, Editor
According to data published in the New England Journal of Medicine in 2011, nearly 15 percent of orthopaedic surgeons are likely to face a medical liability claim each year, and the cumulative likelihood of an orthopaedic surgeon facing such a claim by the age of 45 is 88 percent. In addition to statistics like this that suggest a flawed system, the tort-based medical malpractice system has not proven to deter substandard care or improve patient safety–and neither has the tort-reform approach to improving the existing liability environment.
Alternatives to tort reform may provide a ray of hope. A recent JAMA article summarized what it calls “a welcome influx of creative initiatives that transcend traditional reforms.” The Mello et al. article evaluates nontraditional approaches that were or are being tested during demonstration projects supported by the Agency for Healthcare Research and Quality (ARHQ). The article devotes much of its space to the so-called communication-and-resolution approach pioneered by the Lexington, Kentucky VA hospital and the University of Michigan Health System. The worth-reading article also covers mandatory presuit notification and apology laws, judge-directed negotiation programs, clinical guideline-based safe-harbor laws, and administrative compensation systems.
In a recent AAOS Now article citing possible barriers to widespread implementation of these and other no-fault approaches to medical liability reform, David Sohn, MD, JD, identifies the trial lawyer lobby as probably the biggest political hurdle that needs to be overcome.