#KeyLIMEPodcast 176: Cutting Edge Surgical Training – Orthopedic CBME

Jason’s selection this week is a case report on an innovative Competency Based orthopedic surgical program rolled out at the University of Toronto. The authors describe the origins and hte design of the program and report their experiences over the first 8 years of its implementation. Read on, and check out the podcast here (or on iTunes!)

KeyLIME Session 176:

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Markku T. Nousiainen, Polina Mironova, Melissa Hynes, Susan Glover Takahashi, Richard Reznick, William Kraemer, Benjamin Alman, Peter Ferguson & The CBC Planning Committee (2018): Eight-year outcomes of a competency-based residency training program in orthopedic surgery, Medical Teacher 2018 Jan 18:1-13

Reviewer: Jason Frank (@drjfrank)


As competency-based medical education (CBME) emerges across the globe, the literature in the early days of the movement has largely reflected its rationale, the theoretical basis, and descriptions of ideal ingredients, such as programmatic assessment. (We know, we were there). This has triggered some criticism and a call for example curricula, implementations, and outcomes. Critics: meet the UToronto Orthopedic group.


Nousiainen, et al set out to describe the development and early experience with a completely innovative competency-based orthopedic surgical program they called the “CBC.”

Key Points on Method

This is essentially a case report of an innovation after 8 years.

The authors describe their competency-based curriculum (CBC) in terms of its origins, design, and experiences. They developed the CBC anticipating the coming of CBME to Canada and because of dissatisfaction with traditional time-based surgical training. (An inspiration from one of the authors, Richard Reznick, currently Dean at Queens University and one of the pioneers of CBME). In contrast to a traditional time-based series of rotations, the new program was launched in 2009 with the following design features:

1. Re-imagining orthopedic curriculum in a modular, spiral series of 21 components over three phases;

2. CanMEDS competencies applied to orthopedics organized as milestones and EPAs;

3. Intensive, early surgical skills training informed by best practices in skill acquisition;

4. Extensive use of simulation for teaching and assessment;

5. New approach to the role of CBC trainees with respect to service vs. education, with “repatriation” of off-service learning activities to the home orthopedic setting;

6. New elaborate assessment scheme that was programmatic, using multiple methods and a much higher frequency of direct observation and feedback;

7. Graduated entrustment; and

8. Progression based on achievement.

The new design was sequenced, involved a low learner: instructor ratio, and emphasized hands-on, simulated application throughout. The group sought permission from their local university and accreditor to scale from a pilot to a full alternate parallel stream within the larger residency program. The program went through multiple iterations.

Key Outcomes

The program was formally evaluated multiple times, including accreditation visits. On each of these reviews, no major weaknesses or concerns were highlighted.

Most graduates completed the program in 20% less time than traditional training (4 vs. 5 years after medical school). All passed their exams successfully and all completed successful post-residency fellowships.

Challenges included:

1. Getting buy-in from colleagues, departments, the medical school, and the accreditor;

2. Costs of the simulation and teaching labs (costs ballooned 15.5x over the course of the 8 years, then later fell to 50% of that);

3. Much greater faculty teaching time;

4. Some learners needing more time to achieve the requisite level of competence;

5. Costs of an extra 0.5 FTE program coordinator;

6. The need for a digital platform for the frequent assessments;

7. The need for much greater faculty engagement and development.

Interesting developments included:

1. Improved digital assessment technology;

2. A shift to greater autonomy and ownership of the curriculum by learners;

3. Enhanced teaching, learning, and feedback practice;

4. Much greater direct observation of learners.


Key Conclusions

The authors conclude that the program was a successful innovation that improved iteratively, was more learner-centred, ensured trainees graduated at a defined level of competence, and was 20% more efficient.

Patient-level outcomes or practice behaviours were not available.

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