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15 Questions for Peter Ferguson about Competency by Design

Peter Ferguson
Peter Ferguson

Q1: What is your assessment of the Competency Based Orthopaedics Curriculum (CBC)?

A: The initial form of the Competency Based Program was a pilot study that was highly successful. It then became mainstream and we found some components harder to implement broadly. It is now working phenomenally well. We can now document the feeling that we have had excellent results. There is no change in the level of competence of the applicants for the program, though the number has been diminished by 20% because of the job market for graduates.

Q2: What is the residents’ assessment?

A: The residents think that it is excellent. We are now in the 6th year. We began with a subset of residents. Seniors who missed it wished they had enrolled in the CBC. The residents during the pilot phase were jealous of those who were chosen to enter the CBC. Fortunately, now all get it. The reason it was so popular with the residents is because they develop technical expertise at an earlier stage. The juniors expect to start hitting their milestones at 4-5 months, e.g. the first milestone, such as fix a hip fracture from beginning to end. There was inefficient use of time in the older system and this has been eliminated, especially the off-service rotations. The program has new rotations, for example, instead of Ward Medicine, the residents shadow the hospitalist at Mount Sinai who manages medical and other hospital problems for hip fracture patients.

Q3: Will other divisions be able to do that, like Urology etc?

A: Unknown. There are some models they could adapt. For example, there is, in addition to the hip fracture, a musculoskeletal module led by Veronica Wadey. She serves as organizer for them to attend clinics in infectious disease, physiatry, genetics, and osteoporosis - with preceptors. This is much more focused and effective than the earlier ward medicine antecedent. Veronica is doing an excellent job arranging this complex module.

Q4: What is the faculty assessment?

A: The faculty have realized that we won’t have “my resident” at all times. The reasons for this include the CBC plus the restriction of duty hours, and the now accepted mismatch in the number of residents compared to the number of surgeons. Our residency once had 60 residents. Currently, we have 48. They don’t work more than they did, and so we use fellows and nurse practitioners. We do not have physician assistants yet, though this may eventually become part of the solution.

Q5: Some surgeons have asked: “how can they learn to be doctors when they just zoom in and out and do procedures?”

A: There is much more emphasis now on the intrinsic CanMEDs roles, for example, on my service, oncological orthopaedics, the role of communicator and professional are carefully attended to. These are CanMeds roles illustrated on the Curriculum map.


Dorry Segev

In their communicator role, we emphasize breaking bad news such as the information that the patient has cancer, or has metastases, etc. The professional role is emphasized at the interdisciplinary oncology conference and during interdisciplinary oncology care. There is a multidisciplinary collaboration to divulge risk, to get informed consent, etc. The metrics for all of these is described in the Journal of Bone and Joint Surgery(1).

Q6: What is the best part of the program?

A: By far, it is repeated rigorous assessment. Our residents were accustomed to being examined constantly in school. Then they entered a five year program -without formal assessment in the past. Now they know that they will have a midterm exam six weeks into the rotation and a 12 week final exam on all of the CanMeds roles and on their technical skills. We don’t pass them if they are not informed. In addition, the rigorous assessment helps us identify dyscompetent or less successful residents early on. In the past, these were not well identified early and remediation did not begin as early as it does at present.

Q7: What are the problems with the CBP?

A: The number one problem is the logistics of scheduling. All the residents are in it, and so we have abandoned the open timeframe, where time was a variable and knowledge a constant in our original formulation. Time is also a constant now. If a resident stays behind on oncology, the spine surgeons in the next rotation are short. It is important that the residents know how to run a service and this includes the timely arrival of the resident and timely completion of the rotation.

Q8: How do you remediate a resident?

A: It’s possible to tailor the program, especially in the area of reading and concentrated learning, though we no longer use the “tea steeping” technique of a longer time until the rotation is fully understood. A second problem is the extra burden on the faculty of doing assessment. IPads and iPhones are helpful, but this is still a problem. It has been helpful to give the residents responsibility for the assessment. If the resident says “I have to do on observed history and physical. Is it ok to do that with you on Tuesday?” it is far more likely that this will be accomplished. In addition, the resident or the administrative staff sends a phone app assessment to the faculty which can be quickly filled out. In the new version, we have refocused on the importance of running a service rather than fixing 30 hips. We have a more longitudinal and less episodic procedural focus.

Q9: Should other divisions adopt the “Competency by Design system”?

A: It gives a much more powerful tool to determine fitness to practice. The legal and ethical implications are important. In the past, it was level 5 evidence on fitness to practice. In the future, all of us will be rigorously tested throughout life. It’s good training to expect it.

Q10: Will it work for the other services?

A: Not in an identical form, but it should help. The basic principles are that they can learn the craft early, that inefficient training can be converted to earlier and more focused skill training, and that evaluation had to be improved. In the new system, evaluation is central. The early technical skill training will be tailored to the particular service. We do not have residents doing spine surgery in their early rotations, but they do do arthroscopy and certain standard operations, saving more complex subspecialties for later. The other divisions will need to work out the spectrum of activities for early and late modules. We have a 2 week prep camp for all residents, and that’s true throughout the Department. In Orthopaedics, we also add a 2-3 week Ortho Prep Camp that is focused on our specialty. Vascular and Neurosurgery have a later Boot Camp during PGY1. I was recently at Harvard and found that they have adopted the boot camp directly from our model.

Q11: Why and how did all this get started?

A: Richard Reznick started the program off, asking Ben Alman, who passed the responsibility on to Bill Kraemer to do it. We are the source of this program. The Royal College now anticipates that ENT/ Head and Neck Surgery and Medical Oncology will be the next programs to move into Competency by Design. It will be harder in some specialties than others, for example adolescent psychiatry might be difficult to put into modules, but the suicide risk question is a technique that people can learn and be tested on, and they will all learn how to apply the lessons from the early experience with Competency by Design.

Q12: What is your advice to residents?

A: Be accountable for your own education at an early stage, don’t float along, or act like wallpaper, take charge of your education, and validate your learning.

Q13: What is your advice to the faculty?

A: It’s not that different from how we have always done it. The big difference for frontline teachers will be learning to assess and record the educational process. The tools are there, and they will simply need to be adapted a little for burr holes or VATS. Professionalism only needs the details of the cases to be altered. There is a CanMeds OSCE once during the PGY3 year with remediation applied on the basis of the OSCE and the evaluation scores. Tim Dwyer, a new member of our division has a particular interest in this educational focus. For example, if a resident has done poorly on breaking bad news or on triage questions, there are readings and exercises. Eventually, other divisions will probably need some Tim Dwyers in their program and may recruit toward that goal. The Division administrators will need to learn and they will probably need help. We have two skilled administrators who can be helpful to them.

Q14: What about patient satisfaction?

A: They seem to be as satisfied as they always have been in my observation. This is a good question to answer with qualitative research. We currently ask the Head Nurse to do a multi-source 360° on residents, using a standard form summarizing the views of the other nurses. However, there is room for more evaluation of this question.

Q15: How are the residents doing on their Royal College exams?

A: All of the residents passed their Foundation exam from the first time, and 7 of 9 were advanced to take their fellowship exam after 4 years. I personally like the idea of a 4 year core followed by a one year Transition to Practice year, for example, in a mini-practice under faculty supervision. That may be a development for the future.


(1) Ferguson PC, Kraemer W, Nousiainen M, Safir O, Sonnadara R, Alman B, Reznick R. Three-Year Experience with an Innovative, Modular Competency-Based Curriculum for Orthopaedic Training, J Bone Joint Surg Am. 2013; 95: e166(1-6)

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