Markku Nousiainen’s Update on the Competency Based Curriculums
Markku Nousiainen
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“Changing a system of education
is difficult, sometimes
frustrating, but persistence
pays off”, says Markku
Nousiainen, Orthopaedic
Surgery’s Program
Director. “Our Division
knew that switching to
the Competency-Based
Curriculum (CBC) was a
good idea, and our experience
since 2009 has shown
it to be true. One of the big reasons why it has been successful
has been the support of our faculty and residents.
The successful outcomes of our program played an important
role in the Royal College’s decision to implement
Competency-Based Medical Education (CBME) in all
postgraduate training programs, through the “Competence
by Design” (CBD) initiative which is running between
2015 and 2022. Several surgical specialties in the United
States are implementing CBD and it is gaining traction
in the United Kingdom and Australia. Our experience,
including our mistakes and solutions, has been very helpful
to those that are implementing similar programs locally
and elsewhere. Richard Reznick (whose idea it was to try a
pilot training program that was competency-based over a
decade ago), Bill Kraemer, Peter Ferguson and I get lots of
calls for advice and we have given many courses in how to
design and implement CBME curricula.”
As Markku learned it, the story of the CBC begins
with a call one day to David Backstein from Richard
Reznick, who said: ‘Let’s give competency-based training
a shot.’ Despite the doubts entertained by other
Divisions, the Orthopaedic Surgery Division (led by
Ben Alman and Bill Kraemer at the time) decided to
implement a pilot training program based on CBME
principles in 2009. With the extensive work in curriculum
redesign by Bill Kraemer and Peter Ferguson,
the training in the Division was significantly modified:
off-service rotations that usually focused on managing
non-clinical “scut work” were eliminated, as the experience
on those rotations did not typically lead to successful
learning outcomes. The Division applied for approval
of the novel training program through the Royal College
and got the ok. The new curriculum allowed for more
efficient and effective learning. Instead of having orthopaedic
residents rotate as the lowest ranking member on
an internal medicine service taking care of less exciting,
often resolved inpatient cases, residents were moved to
the medicine consult service, where the experience was
more demanding and relevant to their career in surgery.
The most important aspect of the CBC program is the
assessments and feedback the trainees receive. Residents
are evaluated intensively at least 3 to 5 times as much as
they were before its inception. Evaluation tools, known
as Entrustable Professional Activities (EPAs), have been
developed to assess trainee competence in the clinic, ward,
operating room, and ER. Faculty sign off on the level of
competence a trainee exhibits in key activities related to
the specialty, such as managing a patient requiring surgery
for a hip fracture or total knee arthroplasty. In addition to
the assessments, residents obtain summative and formative
feedback on their progress, allowing them to understand
where they are on their learning curve.
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The pilot version of the CBC ran into one big challenge.
Initially, trainees would stay on rotations until they
achieved competence in the skills targeted for that service.
This led to significant scheduling problems, as some trainees
would need either more or less time on a rotation until
they were found to be competent. In fact, two-thirds of the
residents in the pilot finished in 4 years instead of the usual
five. The program went back to a time -based curriculum in
2013 in order to solve the scheduling problem. Currently,
the vast majority of trainees complete the core training rotations
in four years; the fifth year has become an opportunity
for enhanced elective or research opportunities to allow the
residents to ‘transition to practice/fellowship’ and to complete
their Royal College exams (This solves the Sandra de
Montbrun’s question: ‘Why are surgeons operating in practice
before they are certified?’ (see Surgical Spotlight article)”.
Markku and his wife Brigid, who is a veterinary technician
from Vermont, are raising three children: 11-year old
Nora is teaching her parents how to use her insulin pump, 9-year old Ester and 6-year old Johannes are active in
sports, dance and music. The family spends time together
at the cottage or by travelling to at least one interesting
place each year (usually coinciding with a meeting).
Markku describes his job as “living the dream of doing
formal research in education while practicing surgery. I
devote one half day per week to research and administrative
tasks, but in fact the only way to do the job
appropriately is by working around the hours dedicated
to clinical responsibilities.
After his Bachelor of Arts Honours Degree from Queen’s
University, Markku completed a Master of Science in
Biology, studying osteomyelitis at the University of North
Carolina at Charlotte. He then completed his medical
degree at the University of Toronto and a Master
of Education from the Ontario Institute for Studies in
Education, specializing in Health Professions Education.
He completed residency training in Orthopaedic Surgery
at the University of Toronto, followed by two fellowships,
one in adult lower extremity reconstruction with Allan
Gross and David Backstein at the Mount Sinai Hospital,
and another in orthopaedic trauma with Dr. David Helfet
at the Hospital for Special Surgery in New York City. While
in New York, Markku looked into the role of computer
navigation and its role in teaching surgeons. The technique
replaces fluoroscopy, reducing radiation exposure by using
infrared or electromagnetic guidance. Although navigation
is very useful for precisely and accurately placing orthopaedic
implants, it is not used by most surgeons due to the
set-up time (which takes about 20 minutes for each case).
Markku relates that “if 20 extra minutes for each case at
Sunnybrook would mean the number of cases completed
each day would be drastically reduced – a problem for
patient throughput in an age of restricted resources”.
Markku works at both of the campuses of Sunnybrook.
He does total hip and knee arthroplasty at the Holland
Orthopaedic and Arthritic Institute. He describes it as “a
great place to be - extremely well-run; a focused factory of
anesthesia, nursing, physiotherapy and surgery”. He also does
trauma surgery at the Bayview campus. He says that the trauma
program is also great – “an excellent collaborative effort of
the surgeons, nurses, anesthetists, ER docs, and allied health
professionals helping patients when it matters most”.
MM
[See related article on Education Day]
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