AAOS INSTRUCTIONAL COURSE LECTURE

NEW ORLEANS, LOUISIANA

ACGME REQUIREMENTS
ICL 311 RESIDENCY ACCREDITATION

MARCH 12, 2010 8:00A.M.– 10:00A.M.

TOPICS

(1) DIVERSITY, WOMEN, AND UNDER-REPRESENTED MINORITIES

(2) DEVELOPING A COMPETENCY-BASED ORTHOPAEDIC

CURRICULUM

RICHARD E. GRANT, M.D.

PROFESSOR OF ORTHOPAEDIC SURGERY
UNIVERSITY HOSPITALS OF CLEVELAND/CASE MEDICAL CENTER
CLEVELAND, OHIO 44106
 RACE/ ETHNICITY AND ORTHOPAEDICS

Over the past 20 years, the percentage of the U.S. population consisting of non-White minorities
has continued to expand. Approximately 300 million people live in the United States: in 2000, 3.5
million U.S. residents were Hispanic, 36 million were African-American, and 14 million were
Asian-American. By 2050, the aggregate of non-White minorities is expected to become the
majority. Under-representation of minority health care providers has a negative effect on public
health, as reflected in racial health disparities linked to chronic illness, excessive comorbidities,
and early demise. Yet today, 80 percent of the 16,000 members of the profession of orthopaedic
surgery are White males. Despite 50 years of effort and multiple programs to increase the
representation of minorities in the health care professions, minority representation remains grossly
deficient.
There is a clear need for minority orthopaedic surgeons who can communicate with and
comprehend a population of diverse patients to provide them with culturally competent care. At a
time of rapidly increasing racial and ethnic diversity, all physicians must practice cultural
competency.

Several authors have explored the extent of existing racial/ethnic discrepancies in the profession of
orthopaedic surgery. Jimenez noted that although one-third of the United States population in 1999
was comprised of Latinos, African-Americans, and Native Americans, only 7 percent of all
orthopaedic surgeons were members of these groups. The 2004 American Academy of
Orthopaedic Surgeons (AAOS) census revealed that 89 percent of certified practicing orthopaedic
surgeons identified as Caucasian; among AAOS candidate members, 80 percent identified as
Caucasian. Asian-Americans constituted 3.8 percent of practicing orthopaedic surgeons and 8
percent of AAOS candidate members. African-American respondents constituted 1.3 percent of
practicing orthopaedic surgeons and 2.9 percent of AAOS candidate members.

Other studies have focused on the racial/ethnic composition of residency programs that are
preparing a new generation of orthopaedic surgeons. England and Pierce reported on the state of
racial and ethnic diversity in orthopaedics in 1999, after examining the selection patterns of
orthopaedic residents during the 12 previoustwelve years prior to publication of their data. The
per. The percentage of diversity of orthopaedic residents during that periodose twelve years
cchanged minimally, as represented by the acceptance of African-Americans, Hispanics, Native
Americans, Puerto Ricans, and Mexican-Americans into orthopaedic residency education
programs. The percentage of Asian and Pacific Islanders quadrupled (2.2 percent in 1983, to 9.8
percent in 1995) during the twelve years of the study. The percentage of White women residents
remained unchanged. White male participation in orthopaedic surgery declined in direct relation
to the increase in Asian or Pacific Islander men.

A similar survey of 159 orthopaedic residency education programs garnered a fifty-six (56) percent
response rate. The distribution of orthopaedic residents and fellows was as follows: White
nNon-Hispanics 84.2 percent; Asians 6.6 percent; African-Americans 3.6 percent; Native
Americans 2.2 percent; Puerto Ricans (1.2 percent); Mexican-Americans 0.8 percent;; and, other

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Hispanics 1.0 percent. African-Americans and Hispanics were under-represented in orthopaedic
training programs compared with their numbers in the general American population.

Jimenez, R.L., noted that although one-third of the United States population, in 1999, was
comprised of Latinos, African-Americans, and Native Americans, only seven (7) percent of all
orthopaedic surgeons were represented by these minorities. Ostensibly, there is a need for
minority orthopaedic surgeons who can communicate with and comprehend a population of
diverse patients to provide them with culturally-competent care. Intrinsic and extrinsic barriers
tend to impede women and under-represented minority medical students from choosing
orthopaedics as a career.

When the 2004 AAOS Orthopaedic Physician census results were published, among the certified
practicing orthopaedic surgeons, eighty-nine (89) percent reported they were Caucasian. Among
AAOS candidate members, eighty (80) percent identified as Caucasian. Asian-Americans
constituted 3.8 percent of practicing orthopaedic surgeons, and eight (8) percent of AAOS
candidate members. African-American respondents constituted only 1.3 percent of practicing
orthopaedic surgeons, and 2.9 percent of AAOS candidate members. In 2004, the overall density
of orthopaedic surgeons in the United States increased to 6.2 per 100,000 population base.

Over the past twenty years, the percentage of the American population consisting of non-White
minorities continues to expand at a steady rate. By 2050, the aggregate of non-White minorities
are expected to become the majority. Despite fifty years of effort and multiple programs to
increase the representation of minorities in the health care professions, minority representation
remains grossly deficient. Under-representation of minority healthcare providers has a negative
effect on public health, inclusive of critical bench marks of racial and health disparities linked to
chronic illness, excessive comorbidities, and early demise. Such systemic deficits can be reduced
or curtailed by increased efforts for the recruitment and development of both under-represented
minority medical students, medical administrators, and full time academic faculty.

Many authors have explored the reasons for the under-representation of minorities in the medical
professions. Intrinsic and extrinsic barriers tend to impede women and under-represented minority
medical students from choosing orthopaedics as a career. Nivet, Taylor, Butts, and Kondwani, et
al., note that the recruitment of under-represented minority faculty is compromised by barriers
resulting from decades of systemic segregation, discrimination, tradition, culture, and elitism in
medicine and academic medical centers. The elimination of barriers to minority faculty would
improve public health, expand the focus of contemporary research agendas, and enhance the
education and mentoring of under-represented minority students.

Some authors have explored under-representation from a specialty-specific perspective. Ayers,

C.E., describes orthopaedic surgery as a specialty attracting an abundance of applicants for limited
residency slots. Performance measures reviewed by most orthopaedic residency programs include
USMLE scores, election to the Alpha Omega Alpha Honor Society, grade point averages, medical
school class rank, personal statements, the Dean's letter, and other letters of recommendation.

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One bThe dynamics of barriers to minority candidates seeking entry into orthopaedic residencies
isnclude the perceptionsense that the under-represented minority applicant pool is inadequate.
Additional barriersfactors include certain methods related to applicant- screening criteria, the
under-represented minority specialty preference, and the perception under-represented minorities
have of orthopaedic surgeons. Performance measures reviewed by most orthopaedic residency
programs include U.S. Medical Licensing Examination scores, election to the Alpha Omega Alpha
honor society, grade point averages, medical school class rank, personal statements, and letters of
recommendation from deans and others.

The systemic deficits can be reduced by increased efforts for the recruitment and development of
under-represented minority medical students, medical administrators, and full-time academic
faculty. Seeking to address this issue, the Accreditation Council of Graduate Medical Education
(ACGME) has adopted program requirements addressing cultural competency by adopting two of
the six core competencies specifically directed toward the development of cultural competency
with a direct link to medical communication skills and professionalism. Other Gebhardt, M.C.,
notes that majority medical students exposed to classmates from diverse cultures and contrasting
life experiences different from theirs enable White male students in an orthopaedic residency to
more effectively interact with female and minority patients as a result of interacting with peers who
are women or under-represented minorities. The overall quality of care and the level of
satisfaction for physicians and their patients are improved by such interaction. Ssuggested
remedies for expanding culturally- competent care include increasing the minority applicant pool
from kindergarten through the twelfth grade, and subsequent recruitingment o f talented minority
students to enter the medical field.

Given the extent of current pipeline deficits, some form of short- term affirmative action is
necessary to increase the level of diversity of orthopaedic residency programs and orthopaedic
faculty. The elimination of barriers to minority faculty would improve public health, expand the
focus of contemporary research agendas, and enhance the education and mentoring of under-
represented minority students. The benefits, moreover, will extend to non-minority students as
well. Gebhardt notes that White male medical students exposed to classmates from diverse cultures
and contrasting life experiences are able to more effectively interact with female and minority
patients as a result of their training experiences. The overall quality of care and the level of
satisfaction for physicians and their patients was improved by such interaction.

Approximately three hundred million (300,000,000) people live in the United States. By 2000, 3.5
million American residents were Hispanic, thirty-six (36) million were African-American, and
fourteen (14) million were Asian-American. By 2050, minority populations will outnumber the
White population. Orthopaedic surgeons in the United States will treat an increasingly diverse
population from a variety of ethnic groups and cultural backgrounds. Jimenez, R.L., explains the
target audience for culturally-competent care education is not just the eighty (80) percent of
orthopaedic surgeons who are White males (N=16,000). All physicians must practice cultural
competency. The Accreditation Council of Graduate Medical Education (ACGME) has adopted
program requirements addressing cultural competency by adopting two of the six core

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competencies specifically directed toward the development of cultural competency with a direct
link to medical communication skills and professionalism.

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 RESIDENT SELECTION CRITERIA:
CHALLENGES FOR WOMEN AND UNDER-REPRESENTED MINORITIES

Thordarson and Patzatkis reported in 2007 that a system for selecting found the selection of best
applicants for orthopaedic residency programs remains elusive. Only fair- to- poor correlations
were noted between athe resident's initial ranking, ranking on graduation from residency, and his
or her their U.S. Medical Licensing Examination (USMLE), LE, American Board of Orthopaedic
Surgery (ABOS), and Orthopaedics-In- Training Examination (OITE) scores. The only relatively
dependable correlation found was between the Orthopaedic In Training Examination (OITE) and
the American Board of Orthopaedic Surgery (ABOS) scores. Faculty did not agree in their
ranking of residents on graduation.

Faculty and applicants, moreover, do not agree as to which criteria are most important for
acceptance in to a residency program. Selection criteria for acceptance into orthopaedic residency
can vary when comparing applicant opinions to those of faculty at academic medical centers.
According to Bajajz and Carmichael's study, faculty favored performance on a local rotation
(externship), class rank, and interview performance as essential determinants. Residency
applicants thought externship performance, USMLE Step I scores, and letters of recommendation
were the three most important determinants of obtaining a residency.

Evarts, C.M., reflecting on the consensus of the American Orthopaedic Association (AOA)
committee charged with studying the processes involved in the selection of orthopaedic residents,
offered the following suggestions to orthopaedic program directors:
1) Use of standardized application forms;
2) fFull disclosure to applicants;
3) cCareful screening of candidates to be interviewed;
4) cCareful planning and implementation of the interview process and interview visit;
5) bBroad faculty representation and discussion of candidates at the time of selection; and,
6) Ddue diligence, when necessary, to resolve incomplete information or conflicting candidate
data.

Mallott, D., et al, emphasized the need to focus carefully on the applicant's behavior, character, and
developing professionalism observed over the course of a four- year medical school curriculum.
Such non-academic factors may play a significant role in determining compatibility between a
medical student applicant and an existent orthopaedic residency program. Specific reference was
made to non-academic factors, such as the candidate's dDean's letter, interview, and other affective
domain issues.

Luri, Lambert, and Grady-Weliky examined the relationship between the Ddean's letter rankings
and later evaluations by residency program directors. Dean's letter rankings were found to serve
as a significant predictor of performance in internship. Medical students identified by the dDean's
letter as performing in the bottom half of their medical school class were most likely to either

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under-perform or over-perform during their first year of pPost Ggraduate training.Year one (PGY-
I).

Turner, Shaughnessy, Berg, Larson, and Hanssen developed a Quantitative Composite Scoring
Tool (QCST) to be applied in a standardized manner for orthopaedic residency screening and
selection, in addition to predicting orthopaedic residency performance. Four predictors were
identified, including USMLE Part I scores, AOA status, junior year clinical clerkship honors
grades, and their QCST score. Outcome measurements consisted of OITE scores, ABOS
Cognitive Examination Part I scores, ABOS Oral Examination Part II scores, and internal
assessments of performance meriting attainment of satisfactory PGY-V (Ppost Ggraduate Yyear
5five) cChief Rresident associate status. Honors grades during the junior year clinical clerkships
were associated strongly with Cchief Rresident performance.

Dirschl, Dahners, Adams, Crouch, and Wilson drew similar conclusions from their analysis of
resident selection criteria and subsequent residency performance. Academic performance and
clinical clerkships in medical school were identified as an important factors. The number of
honors grades on medical school clinical rotations was their strongest predictor of residency
performance; . AOA status was second.

In anothern additional study examining the reliability of a scoring system for orthopaedic
residency, Dirschl concluded that no bench marks existed by which to define an acceptable intra-
class correlation coefficient of a scoring model for resident applicants. Great intra-observer
variability existed when subjective elements were included in residency screening scoring systems.

Orthopaedic residency programs must first determine what data elements are essential and highly
valued in their selection of residents. While systems based on calculating objective academic
scores increase the objectivity of the residency selection process, such scoring systems do not
appear to correlate with outcomes of residency education programs.

An additional study by Carmichael, Westmoreland, Thomas, and Patterson evaluateding the

relation of residency selection factors to subsequent OITE Orthopaedic In Training Examination
performances, and they concluded those residents who previously scored 220 on the USMLE Step
I had higher OITE scores than those scoring below 220. Additionally, it was noted that rResidents
who were married also had higher average OITE scores than unmarried residents. A trend with
regard to AOA status was also detected. Residents who attained AOA status scored slightly
higher on the OITE. Obviously, few pre-residency variables correlate well with success during an
orthopaedic residency. Even so, orthopaedic surgery remains one of the most competitive
specialties, with more than a ninety-nine (99) percent match fill rate in the past several years. An
over-supply of qualified applicants leads to intense competition for these limited residency spots.

Thordarson's and Patzatkis study found a poor correlation between USMLE Part I scores and an
applicant's position on their residency's program’s initial rank list. Smilen, Funai, and Bianco
questioned whether interviewers should be given applicants' USMLE Part I scores, maintaining.

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that Kknowledge of those scores by interviewers of USMLE Part I scores may negate the
interview as an independent means of evaluating potential rresidency candidates. Edmond,
Deschenes, Eckler, and Wenzell found that ifif USMLE scores are used to screen applicants for
residency interviews, a greater percentage of African-American applicants would be refused an
interview.

Gilbert, et al., observed increased difficulty with comparing candidates if the interview process
changeds with each candidate. Structured interviews were preferred. Structured interviews
employ standardized questions for all applicants, provide sample answers for comparison, and
utilizes a panel for the interviews. The reliability and validity of the interviewing process
improves as structure is added. In general, residency programs agree in principle about the
important characteristics of a good resident. However, each program's perception of how itthey
values certain resident characteristics, and how those characteristics might manifest in their
resident’s eventual practice profile, may differ considerably. Ultimately, tThe identification of
accurate selection criteria for residents is becoming increasingly important due to the economic
pressures of current and future health care funding and diverse societal forces.

Clark, R., et al,. noted that deficiencies in the affective domain (character and personality traits)
were the most common reasons leading to discipline or dismissal of residents and may serve as the
primary indicator of the resident's ability to function professionally as an orthopaedic surgeon.

Dale, Schmitt, and Crosby focused on the misrepresentation of research criteria by orthopaedic
residency applicants. Berstein, Jazrawi, Della Valle, and Zuckerman's analysis of residency
selection criteria highlighted the relationship between the candidate's affective domain and
his/hertheir performance during residency and practice. The authors anticipated the increasing
importance of issues relevant to affective domain characteristics. They concluded that affective
domain characteristics shwoould play a more important role in future residency selection
committees' deliberations.

White, A.A., questioned the selection process for orthopaedic residents, indicating that programs
must put the horse (that is,, namely the consideration of certain societal goals and responsibilities),
before the cart. (that is, The cart was identified as the selection criteria and processes for selecting
residents into orthopaedic educational programs).

White concluded that one of the specific outcome goals that should be identified are efforts that
can be directed to learning to recognize and evaluate characteristics of applicants that predict
desired outcomes in competency. Traditional screening and selection of applicantsmethods, based
largely on grades, test scores, and election to Alpha Omega Alpha Hhonorary sSociety, have
certain historically- based biases and limitations. The historic ethnocentric impacts on wWestern
medical culture are profound, longstanding, and thoroughly interwoven into the fabric of the our
profession, oorthopaedics profession. White further concluded it is necessary to substantially
change our residency selection process if we hope to achieve some highly- significant
humanitarian and pragmatic societal goals.

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8
 ACCREDITATION COUNCIL OF GRADUATE MEDICAL EDUCATION (ACGME)
CORE COMPETENCIES AND THE DEVELOPMENT OF A COMPETENCY-BASED
ORTHOPAEDIC CORE CURRICULUM

Since the beginning of July of 2002, Accreditation Council of Graduate Medical Education
(ACGME)-accredited programs in the United States have been challenged to teach and assess
competency-based curriculaums and better prepare residentsphysicians in residency programs to to
practice in the rapidly- changing health care environment. Current accreditation requirements for
residency education programs mandate that residents are to participate in educational experiences
that ensure attainment in six general competencies: patient care; medical knowledge; practice-
based learning and improvement; professionalism; interpersonal skills and communication; and,
systems-based practice. Competency in these six areas must be documented by dependable and
appropriate metrics or evaluation tools confirming an incremental growth in professional
knowledge, patient-centered care, and orthopaedic surgical skill acquisition.

Arnold, L., favors quantitative and qualitative approaches to the assessment of the desired level of
professionalism implicit in the framing of the six competencies. Techniques of assessment
increasing the validity and reliability of measuring a resident's progress include 360 assessments,
performance-based assessments, learning portfolios, and system designs inclusive of infrastructure
support.

Resolution of a resident's unprofessional behavior would be addressed through due process

documented by a warning, and constructive confrontation to institute a structured program of
remediation. There should be concordance between the intervention and the etiology of the
resident's lapse in professional behavior. The essentials of effective behavioral contracts are
includsive of cognitive behavioral therapy, motivational interviewing, and continuous monitoring.

According to Cruess emphasizes that , one of the six competencies, professionalism, must be
explicitly taught. Once the concept of professionalism is defined and learned by residents and
faculty alike, residents will require reinforcement through example. Residents must understand
what will be taught, expected, evaluated, and incorporated into the knowledge base of residents
and practicing faculty members. Cruess advocates specific learning experiences, includings
inclusive of self-reflection on professionalism and the adaptation of such practices into the
continuum of medical education.

Cornwall concluded it is unlikely that professionalism is an innate or universal characteristic of

college students entering medical school or of medical students entering a program of postgraduate
residency education. Regardless, the core competency, professionalism, is becomes an essential
value in effective medical practice.

Beach, Bar-On, Baldwin, Kittredge, Trimm, and Henry evaluated the use of an interactive, on-line
resource for competency-based curriculum development. Program directors were allowed to
download competency-based curriculum building tools using a specific web site. Most users

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favored pre-designed formats over self-selected lists of goals and objectives. Less frequently, web
site subscribers downloaded resident evaluation forms and tutorials. Respondents to the
association's educational guidelines for residency training confirmed that the on-line, competency-
based curriculum building tools were easy to use, adaptable, and important to the understanding of
mechanisms for integrating the ACGME competencies into their residency programs.

Lurie, Mooney, and Lyness evaluated published evidence that the ACGME's six general
competencies could each be measured in a valid and reliable way. Fifty-six (56) of 127 articles
identified met their inclusion criteria. Studies of systems-based practice and practice-based
learning and improvement demonstrated that viewed these competencies wereas inherent
properties of systems and that they were not specific to individual resident behavior. Theisr
review of the literature cited a lack of evidence that current core competency measurement tools
were able to asses the six competencies independently of one another.

Varkey, Karlapudi, Rose, Nelson, and Warner conducted a residency program director self-
assessment survey following a web-based, institution-wide curriculum designed to facilitate the
teaching and assessment of practice-based learning and improvement (PBLI) and systems-based
practice (SBP) in 115 ACGME-accredited residency and fellowship programs. Additional
initiatives included didactic sessions for residents and fellows, program director workshops, and
one-on-one consultations with program directors. While tThe authors documented a thirteen (13)
percent increase in a program directors' perceived ability to measure competency in one area,
systems-based practice (SBP), but found there was no change in the program directors' perceived
confidence in the measurement of program-based learning and improvement (PBLI).

Carraccio and Englander reviewed the current literature for all articles relevant to assessment of
the six competencies and resident performance. Their evaluation of current "best practices"
endorsed the use of a web-based evaluation portfolio, allowing faculty and program directors a
variety of assessment tools to evaluate the diverse domains of competence and reflective learning.
Their web-based portfolio assessment program facilitated the evaluation of resident competence
and enhanced the faculty research infrastructure supporting theirir practice of evidence-based
education.

Yaszay, Kubiak, Agel, and Hanel conducted a national survey of orthopaedic program directors
and selected orthopaedic residents in an effort to define the experiences of orthopaedic residencies
working toward the incorporation of the ACGME's core competencies. Residents and program
directors prioritized patient care and medical knowledge. PBLI and SBP's were relegated to the
lowest level of priority among the six competencies. Orthopaedic program directors and residents
suggested: (a) greater clarification of the definition of each of the core competencies; and, (b)
greater commitment to the processes relevant to the development of competency in surgical
procedures.

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Lee, et al,. favored best practices for residency journal club activities and group discussion of
existing medical literature. The core competency of PBLIpractice-based learning and
improvement was enhanced by the use of a structured review checklist, explicit written learning
objectives, and a formalized meeting structure and process. While Rosenfeld advocated the use of
a redesigned residency the residency program's morbidity and mortality (M&M) conference to
teach and assess the ACGME general competencies for instruction in PBLI, professionalism,
interpersonal and communication skills, and SBPsystems-based practice. During the redesigned
M&M conference, residents present the selected patient's history and discusses the complications
according to traditional morbidity and mortality conference models. However, the resident is also
required to analyze the case presentation in terms of health care system issues contributing to the
patient's morbidity or mortality. In addition, the resident is tasked with identifying patient safety
issues, and communication problems with the patient, the patient's family, andor with colleagues.

Issues relevant to ethnic dissonance, ethical issues, and challenges of ccultural competency are also
identified and explored by the resident. Subsequently, as an example relative to this process, the
case presented is reviewed by faculty orthopaedic surgeons. Each ACGME competency is
addressed as deemed relevant to the facts and outcomes of the case presentation. Each resident
presenter completes a practice-based improvement log, analyzing factors precipitating the
complication and/or the mortality. The resident is then tasked with providing suggestions for
systems improvement, increasing patient safety, improving communications and ethnic cultural-
competency, or addressing ethical issues. References from the literature supporting solutions for
improved outcomes areshould be included in the resident's practice-based learning and
improvement log.

Stiles et al. have suggested aAnother method to teach the core competencies to orthopaedic
residents and faculty, and to determine whether both parties are satisfying the intended outcomes
related to the core competencies has been suggested by Stiles, et al. Their general surgery
program initiated a daily morning report as an effective "sign-out" and accounting of new
admissions and consults from the previous day to their surgery service.

The morning general surgery report was restructured and presented in an evidence-based format
addressing patient care, medical knowledge, professionalism, interpersonal skills and
communications, and PBLIpractice-based learning and improvement. Their guidelines included
the participation of the on-call Aattending, a review of all the pertinent imaging studies, provisions
for follow-up of selected cases, and a critical review of the peer-reviewed literature. Surgical
morning report and traditional orthopaedic fracture conferences appear to be very compatible with
existent resident didactic sessions, and the incorporation of ACGME competency requirements.

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 RACE ETHNICITY AND ORTHOPAEDICS
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 RESIDENT SELECTION CRITERIA:
CHALLENGES FOR WOMEN AND UNDER-REPRESENTED MINORITIES
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 ACCREDITATION COUNCIL OF GRADUATE MEDICAL EDUCATION (ACGME)
CORE COMPETENCIES AND THE DEVELOPMENT OF A
COMPETENCY-BASED ORTHOPAEDIC CORE CURRICULUM
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