Elements of a Successful Program

Knee arthroscopy


Shoulder arthroscopy


Anterior cruciate ligament reconstruction


Total hip arthroplasty


Total knee arthroplasty


Hip fractures


Carpal tunnel release


Spine decompression/posterior spine fusion


Ankle fracture fixation


Closed reduction forearm/wrist


Ankle and hind and mid-foot arthrodeses


Supracondylar humerus percutaneous treatment


Operative treatment of femoral and tibial shaft fractures


All pediatric procedures


All oncology


The effects of case log minimums have yet to be seen. In a recent survey, residents consider case minimums as an effective monitoring tool of resident progress, but surgical ability is difficult to evaluate based on minimums alone [14]. There is much variability in clinical exposure to surgeries, and case volume is not the only determinant of training quality, since case complexity, breadth of pathology, and teaching quality influence the learner’s experience [15]. While using minimums as a benchmark for surgical ability is crude at best, the objective structured assessment of technical skills (OSATS) and associated checklist scores aim to bring validity [16]. However, the improved validity of OSATS scoring does not necessarily translate into better surgical results [17, 18].

Institutional Support

Among the program requirements for orthopaedic surgery residency, the sponsoring institution must assume responsibility for the program, and this responsibility includes oversight of all participating training sites [9]. The sponsoring institution must also have accredited programs in general surgery, internal medicine, and pediatrics, so that the residents are able to have an interdisciplinary experience.

In addition to the oversight of training sites, the institution is responsible for ensuring adequate time and availability of the Program Director (PD) and support staff. The PD must have sufficient protected time and institutional financial support so that administrative and educational responsibilities can be met. In addition, the Program Coordinator is responsible for assisting in providing effective administration. For large programs, where there are more than 20 residents, additional administrative personnel should be provided.

Institutional support extends to educational resources. These resources include specialty-specific full-text journals and reference books accessible by electronic means. The most common access is through Internet log-in, where residents at remote affiliated sites have the ability to readily view articles and texts. Additionally, institutional support includes making sure that there are adequate workspaces for the residents, with access to computer resources for research, writing manuscripts, preparing presentations, and upkeep of portfolios. Most programs incorporate anatomy sessions with cadaver dissections, focusing on surgical approaches. While few programs include formal microsurgical training, we give our residents 40 h of instruction on mice. More recently, with the additional requirement of basic surgical skill instruction, dedicated space must be available, and future requirements may include simulation training.

Beyond institutional support, orthopaedic departments also provide additional benefits to residents. More than three-quarters of residents receive discretionary funds and funding to attend conferences. A recent survey found that most of these funds came from the department, followed by funding from the hospital or institution. Nearly all programs provided meal stipends, and the majority gave free parking, gym benefits, surgical loupes, and maternity/paternity leave beyond vacation time [19].

Research Support

Resident research is an essential component of an orthopaedic residency program [20]. Towards this end, several elements of support are necessary to help achieve meaningful research productivity. A mechanism for resident research funding at a basic level, institutional review board application submission, and collaboration with other laboratories/departments provide for an environment where resident research can be successful [21].

Within our institution, initial funding for approved orthopaedic projects comes from a departmental fund that creates a small budget for residents to start pilot studies and/or purchase material for their research. In addition, residents are encouraged to apply for research grants available nationally. Within our department, there is an administrator who assists with obtaining approval from the Institutional Review Board (IRB) and works with Grants Management. The institution also provides formal statistical consultation to assist with resident research.

Multidisciplinary collaboration across departments allows for better resource utilization for conducting research. We have a biomechanics laboratory with a dedicated researcher to help residents set up appropriate mechanical testing models. In addition, the Research Director maintains contacts with various departments such as radiology, physiatry, and neurosurgery, as well as basic science labs at the institutional level allowing residents to utilize bench space and obtain basic science expertise for their projects.

Several members within the department are essential to assisting residents with their research. At our institution, the members that form the Orthopedic Research Committee (ORC) consist of a research-oriented orthopaedic clinician who acts as the Research Director, the Program Director, all residents on research rotations, a basic scientist specialized in biomechanics, and administrative personnel who assist with the research database and IRB applications. The ORC meets monthly to review all research proposal presentations, discuss logistical issues pertaining to research, and plan for the annual department research seminar.

Being a Successful Program Director

Responsibilities of the Program Director

The first priority of the Program Director (PD) is to ensure the quality of education for all residents at all participating sites. Quality of education includes both didactic and clinical components. At each participating site where residents rotate, the PD approves the local director as well as approves the selection of all new faculty members associated with the program. Continued participation of program faculty members is based on routine faculty evaluations completed by residents after each rotation.

To safeguard the learning environment, the PD must make sure that ACGME and institutional policies and procedures are implemented. This includes ensuring adequate supervision at each participating site, monitoring policy, adherence to duty hours, adjusting schedules to mitigate fatigue, and providing access to online educational resources [9].

The PD is also responsible for monitoring data for process improvement. This information comes by way of evaluations and surveys: evaluations of residents; the residents’ evaluations of faculty members, rotations, and program; and past graduates’ evaluations of the program. These will be detailed later in the chapter.

With the many varied responsibilities of the Program Director, a calendar is helpful. Our program developed this calendar to aid in staying on track (Table 11.2). The keystone meeting is the Residency Program Evaluation Committee (RPEC), which is convened on a semiannual basis; all evaluation data are reviewed and recommendations for program improvement are made. We also have other committees that enhance program administration. Twice a year, we hold a Resident Forum, where the PD and Associate Program Director (APD) meet with all the residents to discuss any suggestions and concerns. Then, between these meetings, the PD meets with the Resident Representation Committee (RRC)—comprised of one member elected from each class—on an as-needed basis to solicit comments and to handle problems. As required by the ACGME, we also convene the Clinical Competency Committee (CCC) ahead of each semiannual Residency Program Evaluation Committee. The CCC reviews data from each resident’s evaluations and pegs performance to the Milestones [22]. While we have not implemented this practice, resident self-assessment using the Milestones may provide personal insight, and one study found that residents were able to successfully self-assess, with improving proficiency over time [23].

Table 11.2
Calendar of program director tasks


• Publish important dates for the academic year

• Publish improvement implementation plan, based on action items derived from the June semiannual Residency Program Evaluation Committee

• Run basic surgical skill course for incoming residents

• ABOS modules for incoming residents

• Arrange fracture course for junior residents

• Oversee fellowship application process for new PGY-4 residents


• Conduct 360° evaluations, including patient surveys, case management surveys, nursing evaluations


• Assemble Resident Selection Committee

• Convene Resident Representation Committee


• Orient members of the Resident Selection Committee

• Draft agenda for the semiannual Residency Program Evaluation Committee

• Draft agenda for the Resident Forum

• Convene Resident Representation Committee

• Conduct 360° evaluations

• Convene Clinical Competency Committee

• Remind senior residents about graduation requirements


• Consider nomination of one or more residents to the Alpha Omega Alpha Honor Medical Society

• Conduct the semiannual Residency Program Evaluation Committee

• Meet with individual residents for semiannual review


• Interview residency applicants and submit rank order list

• Arrange board review course for senior residents


• Convene Resident Representation Committee

• Conduct 360° evaluations

• Finalize details for the Orthopaedic Research Seminar


• Send out goals and objectives to all services for updates and revisions

• Solicit from faculty members any potential changes or suggestions to current policies and procedures

• Select Program Resident Representative for American Orthopaedic Association Resident Leadership Forum


• Draft conference schedule for next academic year

• Plan residency graduation events


• Update Residency Program Policies and Procedures and send out to faculty members for review

• Draft agenda for the Residency Program Evaluation Committee

• Draft agenda for resident forum

• Invite guest professor for next year’s Orthopaedic Research Seminar

• Solicit evaluations from faculty members, residents, and past graduates regarding the training program

• Convene Resident Representation Committee

• Conduct 360° evaluations

• Convene clinical competency committee


• Perform exit interviews with senior residents

• Conduct the semiannual Residency Program Evaluation Committee

• Meet with individual residents for semiannual review

• Meet with Chair to discuss faculty development and advancement

• Re-administration of ABOS modules for completing PGY-1s

Building a Team

A successful residency program requires a well-functioning team, and the key components of this team are the Associate Program Director (APD), Program Coordinator, and core faculty members.

Associate Program Director

The Associate Program Director (APD) , along with the Program Director (PD), carries authority and accountability in maintaining the residency program [24], particularly in programs with greater than 20 residents. The APD serves to assist, and, at times, stand in the stead of, the PD. The APD allows for continuous access for the residents to the staff and core faculty of the Residency Program. In addition to being the liaison between the residents and the program, the APD also serves to further aid in core faculty development within the residency. The APD collaborates with the PD to optimize scheduling and ensure adherence to ACGME policies, recommendations, and deadlines.

Program Coordinator

The role of the Program Coordinator is becoming increasingly important. From initially being more clerical, the increased requirements of the ACGME—from the Outcome Project to Milestones implementation—have driven the Coordinator’s role to be more managerial. One survey found a high level of day-to-day managerial oversight of all aspects of residency training, and often, there are additional responsibilities for faculty development and other business [25]. Because of the complexities of managing a residency, of assisting the Program Director in assuring compliance with current policies and maintaining accreditation, we recommend professional certification of the Program Coordinator. Training Administrators of Graduate Medical Education (TAGME) certification assures knowledge in key knowledge content areas, including milestones and competencies, evaluations, procedure logs, and other ACGME-related regulations. Engagement in the Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) provides a forum for support and enables the coordinator to keep up to date with current recommendations and best practices.

Faculty Members

The biggest recent change, and perhaps a challenge, in educating the program’s core faculty members came with the advent of competency-based education. To many faculty members who trained in the pre-competency era, much of the terminology remains nebulous. For instance, despite advances in defining systems-based practice competency, a recent study of orthopaedic educators and residents found that the teaching of this domain is highly inconsistent, and formal assessment rarely happens [26]. However, current guidelines mandate that training be mapped to core competencies, and with work-hour limits available for clinical training, rotations based on competency, rather than on time, may be the answer in maximizing the use of available hours [27].

While all faculty members have spent their lifetime in education, few are trained in education. One successful and highly recommended faculty development program is sponsored by the American Academy of Orthopaedic Surgeons (AAOS). We encourage each of our faculty members to attend this week-long AAOS Course for Orthopaedic Educators at least once. Upon returning, each faculty is given an opportunity to share points learned during a departmental meeting. These experiences enrich the faculty member, giving each one a better understanding of competency-based training, a sense of community with other orthopaedic educators, and tools for setting expectations, providing feedback to residents, and working with problem residents. Additionally, we invite speakers for Grand Rounds, and educational topics (such as recognizing resident fatigue) are covered several times a year. At the institutional level, our GME office holds a 1-day retreat for the Program Director, the Associate Program Director, and the Program Coordinator, where didactic sessions are mixed with case-based discussions on topics pertaining to resident education.

Meeting the ACGME Standards

Graduate Performance

Ultimately, residency training produces graduates who are able to independently practice orthopaedic surgery without supervision. While this is difficult to fully assess, there are several measures of graduate performance. The American Board of Orthopaedic Surgery (ABOS) provides Part I and Part II scores to the programs, and the Part I scores are subdivided into domains. How a resident performs on the Orthopaedic In-Training Examination relates to ABOS Part I scores [5, 2830], but certification is contingent on passing the both Parts I and II. One benchmark is to compare program pass rates to the national average, which is between 79 and 88% [31].

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Mar 10, 2018 | Posted by in ORTHOPEDIC | Comments Off on Elements of a Successful Program

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