Bone-Doctor Boot Camp

In the late ’80s, when John Gorczyca, MD, was working as an orthopaedic resident at Dartmouth-Hitchcock Medical Center, finding time to eat during his shift was an unexpected luxury. If he or his colleagues saw food, they ate it, no matter what it was, because they didn’t know when they’d have a chance to eat again. Long hours on duty could stretch into days, and Gorczyca often didn’t know when he’d be able to catch any shut-eye at the hospital, let alone sleep in his own bed.

Like others in his class, Gregg Nicandri, MD, fought fatigue during hours-long lectures that sometimes put residents to sleep— even the unfortunate ones sitting in the first row. And, as a first-year resident at the University of Washington Medical Center in 2004, Nicandri would purchase raw pigs’ feet at the grocery store to practice his suturing techniques, anxious to acquire the fundamental skills that weren’t taught until his third year.

If you had told Gorczyca or Nicandri during their training that one day residents like them would have a healthier work-life balance—and be taught hands-on surgical skills in the first weeks of their residencies to boot—they probably would have thought to themselves, “When pigs fly.”

But that day has arrived, and both doctors have played a large part in helping these innovations take flight in Rochester. Not only have they rewritten the rules for orthopaedic residency training at the School of Medicine and Dentistry, but their approaches are drawing attention from academic medical centers around the country.

Gorczyca, the Dr. C. McCollister Evarts Professor in Orthopaedics, is chief of the department’s Trauma division, and director of the residency program. Nicandri, an assistant professor, is an orthopaedic surgeon, a faculty instructor in the residency program, and a master instructor for the Arthroscopic Association of North America. Both will assert, and their careers attest, that they received excellent preparation to become surgeons and teachers. They recall their own training as being the highest standard for the time, which wasn’t so long ago. Gorczyca completed his residency in 1993 and Nicandri in 2008.

But since then, a great deal has changed in how orthopaedic surgery is practiced and taught, including:

• A shift from traditional, open surgeries to minimally invasive procedures that demand different skills;
• Increased emphasis on patient safety at academic medical centers nationwide, which can limit residents’ experience in the operating room;
• Federally mandated and/or independently imposed work-hour limits that have helped improve residents’ lifestyle and well-being, but can also mean less on-the-job learning;
• And, new regulations from the Accreditation Council of Graduate Medical Education (ACGME) that require more sophisticated, and more frequent, assessment and documentation of residents’ skills throughout their training.

Perhaps the biggest and most important change of all, however, is the residents themselves. Today they possess widely varying learning styles, have different definitions of what work-life balance means, and hail from far more diverse cultural and socioeconomic backgrounds than their predecessors.

“Residency programs like ours need to roll with the changes but also be tuned in to what’s coming around the corner, and what the expectations are going to be on these young physicians,” says Gorczyca. “It’s not ‘one size fits all’ anymore in terms of how you train students, and we need to constantly evolve to keep up with rapid advancements in our field.”

Senior associate dean for Graduate Medical Education Diane Hartmann, MD, says the secret of Rochester’s success in physician training has always been “its ability to anticipate the needs of incoming residents, and stay ahead of the ways every specialty is changing. The Orthopaedic Residency Program is a perfect example of how residency programs across our Medical Center are evolving to make us one of the best places to learn in the country.”

Getting ‘Boots on the Ground’ Earlier

Traditionally, up-and-coming surgeons hone their craft through apprenticeship: observing surgeries, applying skills in the operating room under the supervision of attending physicians, and eventually instructing other residents and medical students.

“‘See one, do one, teach one,’ has long been the mantra,” says Nicandri.

But in recent years there has been a move to develop safer teaching opportunities outside the doors of the OR in order reduce any possible risk to patients, he says. Additionally, the expeditious, patient-centered OR environment is limited in the amount of teaching time it can offer young doctors.

“We conducted a study in which medical students followed residents and logged what they did every day,” he says. “For each eight-hour day, the average resident had their hands on an instrument in an OR for only 90 minutes. That means they are only getting about 1,400 hours of hands-on training in their entire residency. Because OR time is so valuable, it becomes critical that they don’t spend precious time learning rudimentary skills like how to tighten a drill chuck.”

To address these educational gaps, about five years ago the ACGME began requiring all medical schools in the country to develop alternative types of surgical training programs. “We were one of a handful of institutions nationwide that was well-prepared for these mandates because we were bringing first-year residents into our surgical skills lab for hands-on practice every week, well before that time,” Gorczyca says.

“We were proud to be ahead of the curve, and have only continued to enhance our program since.”

In 2015, the residency program upped the ante by creating a “boot camp,” an immersive 30-day training experience for interns. Taking place during the fourth month of every resident’s first year, the camp culls the curriculum of each of Orthopaedics’ 13 divisions, and is taught by a cross-section of faculty from each specialty.

Every weekday in October, interns spend the morning and evening in normal patient care activity, but devote four hours of the afternoon to boot camp classes in the DeHaven Orthopaedic Skills Laboratory within URMC’s Sawgrass Surgery Center. Residents start with simple tasks, and over the next 30 days progress through a packed curriculum that puts a variety of surgical tools in their hands. They thread needles to suture skin on cadaver parts or a medical model. They hoist drills to set fractures, and screw plates into artificial bones. They command a surgical simulator—guiding arthroscopes and instruments while the device measures their speed and accuracy.

On the boot camp’s opening day, interns Andrew Liu, MD, Bowen Qui, MD, David Quinzi, MD, Steven Samborski, MD, Matthew St. John (MD ’17), Eric Vess, MD, and Zachary Zmich, MD, gathered for the first lesson: tying knots. The residents drew together in a tight circle around Nicandri as he spoke, their eyes locked on the surgeon’s hands as he spun knot after knot in rapid, fluid movements.

Then they divided among the lab’s work tables to practice. At each session, every resident gets the tools and time to try a new skill, learn from mistakes, and refine their techniques. Faculty members are close-by to observe, instruct, and answer questions. Among residents, there’s plenty of cross-chatter as they work, comparing results, competing to be the best, but always offering one another constructive feedback and encouragement.

The camp ends with a skills competition that scores residents on speed, accuracy and efficiency.

“Our goal is to get everyone to the same baseline before they’re too far along in training,” Nicandri says. “The experience enriches every lesson they receive down the line. After one month at this, they’re asking more pertinent questions and learning at a higher level.”

Residents thrive in the low-pressure, supportive learning environment. “It really helps to get your hands on the drills and other tools,” says Qui. “A lot of times, you don’t get to touch them until your third year, and by then, it’s terrifying. It helps you retain things better when you’re not a deer in the headlights in an operating room.”

The boot camp is one of the reasons St. John stayed in Rochester for his residency after graduating from medical school here, he says. “Rochester takes its time to train everyone at every level, starting with interns,” he says.

“In a lot of places interns feel like the bottom of the barrel. Here, it shows how much they want us to succeed from the start.”

The boot camp demands a heavy investment of time for residents and the approximately 20 faculty members who assist Gorczyca and Nicandri in teaching. But all agree that the program reaps dividends by building residents’ technical skills and confidence at a critical juncture, while nurturing their fresh enthusiasm about the field.

Residents are quick to point to a benefit that holds even deeper meaning for them.

“The best part was getting to meet my attending physicians and fellow residents,” says Qui. “These are people we will be spending the next five-to-six years with. It’s a true mentorship model, because it allows you to meet your mentors in a less-formal setting than an operating room.”

Observing residents early in their training also gives faculty an edge in identifying unique skills and goals of trainees, while establishing positive work relationships.

“Otherwise, some faculty won’t meet these residents until their fourth year,” says Gorczyca. “Plus, teaching residents keeps you (as a faculty member) sharp,” he adds. “What we see is that they keep getting better, smarter, more hard-working and more talented every year.”

The Medical Center is now trading ideas with other leading medical schools around the country, such as Duke and Vanderbilt, as they build or expand their own boot camps for teaching basic surgical skills.

“This is a hard program to put together from scratch because it takes a lot of coordination,” Nicandri says. “Other programs have heard about what we’re doing, and it’s flattering to be asked about our approach. We are totally willing to share our ideas, and to learn from what they’re doing as well.”