What’s Important: Integrating Undergraduate and Graduate Medical Education in Orthopaedics

One hundred years ago, most medical school graduates entered practice immediately; structured postgraduate training was uncommon. Today, nearly all of the medical school graduates in the U.S. complete residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME), and many pursue 1 or more years of fellowship training. Certainly, there is more to learn today, but it is also clear that “learning to learn” (continuous inquiry, self-assessment, and incorporation of new information and skills) is equally important. The education of a physician is expensive. The cumulative expense of tuition, fees, and living expenses for undergraduate college and medical schools often exceeds $600,000. Amortized over 20 years, the total cost easily can exceed $1,000,000. The cost to academic health centers also is substantial. The institutional direct and indirect costs of medical education are growing at a time when reimbursement for graduate medical education is decreasing. Efforts to improve efficiency and reduce cost are essential1. Integration of the medical school curriculum and the first year of postgraduate training is a practical approach. Although the educational methodology of the first 3 years varies in U.S. medical schools, curriculum content is relatively uniform, in large part because of the norming effect of Steps 1 and 2 of the U.S. Medical Licensing Examination. There is, however, little standardization in the curriculum content, learning objectives, or assessment methods for year 4. Individual student experience is variable, learning often is fragmented, and assessments are unreliable. Program directors have very little idea about the competencies of incoming residents, and, consequently, much of the first year of postgraduate training is spent bringing new residents to common levels. Medical schools, the Association of American Medical Colleges (AAMC), specialty boards including the American Board of Orthopaedic Surgery (ABOS), and the ACGME have made substantial progress in setting respective expectations. Not surprisingly, there is substantial overlap with the expected competencies in the fundamental skills of history-taking, physical examination, differential diagnosis, and interprofessional communication. If undergraduate medical educators and postgraduate program directors collaborate in curriculum design and delivery, seamless integration of undergraduate and graduate medical education is possible. Changing the Paradigm The Liaison Committee on Medical Education (LCME), the accrediting body for U.S. medical schools, requires 130 weeks (3 years) of instruction for the award of the MD degree. Most U.S. medical schools have a 4-year curriculum, a legacy of the 1910 Flexner Report. There are no impediments to shortening the undergraduate phase of medical education as long as the curriculum exceeds the 130-week threshold and meets general LCME guidelines for curriculum content, delivery, assessment, and student well-being. All state, U.S. commonwealth, and U.S. territorial medical boards accept the LCME 130-week guideline as the basis for licensure. The ABOS requires 60 months of postgraduate training for Board eligibility2. Modifications to the length of training require a waiver from the ABOS and approval by the Residency Review Committee (RRC). The ACGME has recently published additional requirements for substantial changes in program duration, educational methodology, and assessment of competency3. Proposals that seek to integrate undergraduate and graduate education must comply with the ACGME’s Advancing Innovation in Residency Education (AIRE) directives. Models for Change A small number of U.S. medical schools offer 3-year MD-degree tracks, either as stand-alone curricula or as a parallel track4. Graduates of 3-year schools meet all of the existing requirements for entry into postgraduate training. A few U.S. medical schools include a year of research in the 4-year curriculum. In these schools, rearrangement of the undergraduate schedule to permit delivery of the 130-week core requirement permits early award of the MD degree. The 3-year programs reduce redundancy and reduce the cost of medical education, but may limit student opportunities5. Many students use the latter half of year 3 and the first half of year 4 to refine specialty choices and participate in elective rotations that enhance residency applications. Graduates of the 3-year programs must choose much earlier, and they have more limited elective opportunities. Because their portfolios contain less information, they may be at a disadvantage when applying for highly competitive residency positions outside of their parent institutions. Competency-based advancement within residency is another approach to reducing redundancy and improving efficiency6. The Canadian experience in competency-based orthopaedic education suggests that some trainees will finish early, most others will finish in the traditionally allotted time frame, and a few may require additional time7. In such a system, subspecialty training could begin during residency. A competency-based advancement system that spans the entire duration of training is theoretically possible, but poses great challenges in a large multi-setting residency program. In orthopaedics (and perhaps in other specialties), a hybrid that blends year 4 with postgraduate year 1 (PGY-1) provides a controlled learning experience and offers the opportunity for competency-based acceleration. The flexibility of year 4 permits the development of a musculoskeletal “track” that satisfies all PGY-1 requirements. If the assessment instruments used in residency are used for students as well, competency-based advancement from medical school to residency is feasible. Mid-fourth-year graduation for students who meet milestones saves a half year of tuition, and permits the opportunity for 6 months of PGY-1-level patient-care responsibility prior to entering PGY-2. Students who complete such a program but do not choose or are not selected for accelerated entry will be excellent candidates for traditional residency programs. Conclusions Integrating the graduation competencies defined by the AAMC with the milestones defined by the ABOS and the ACGME eliminates redundancy and sets uniform expectations for students considering a career in orthopaedics. When combined with competency-based advancement systems, this integration offers the additional opportunity to accelerate training for qualified candidates, reduces costs for learners and the institutions where they train, and ensures adequate training opportunities for all.

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