SIM-integrated education model producing more competent surgeons in less time

SIM-integrated education model producing more competent surgeons in less time
August 04, 2015

The University of Toronto’s Division of Orthopaedic Surgery’s move towards competency-based education

The University of Toronto’s Division of Orthopaedic Surgery is using simulation and competency-based education to produce more competent surgeons in less time.

Simulation is an essential component of the Division’s novel competency-based education (CBE) model. CBE emphasizes regular assessments to determine core competencies, and relies heavily on simulation to safely emulate skills and scenarios traditionally learned in the high-risk clinical environment.

Using simulation a “no-brainer”

“Using simulation is a no-brainer,” said Dr. Markku Nousiainen, Director of the University of Toronto’s Division of Orthopaedic Surgery Residency Training Program. “The old paradigm of ‘see one, do one, teach one’ is over and doesn't work as effectively as simulation. In the past, you would just presume that residents would be competent after five years of residency. Now, they're regularly assessed to determine if they're competent.”

As a result of the Division’s education paradigm shift, some of its residents are now graduating in four years rather than the traditional five years of residency.

Orthopaedic simulation bootcamp

The Division first experimented with CBE in 2009 when it conducted research comparing first-year residents who underwent the Division’s intensive month-long CBE “Orthopaedics Bootcamp” with residents who learned through a more traditional model. The bootcamp featured many orthopaedics-related simulation scenarios, such as prepping and draping a patient, fixing a broken bone, and applying a cast. The outcomes of the bootcamp were astonishing. The residents who went through the bootcamp outperformed their peers in assessed targeted skills and displayed similar levels of competency to senior residents. This high level of competency remained with the residents during retention tests of competence at 18 months following the bootcamp​.

Photo: Cutting bone simulation at Orthopaedic Bootcamp, University of Toronto Division of Orthopaedic Surgery.
Photo: Arthroplasty simulation, University of Toronto Division of Orthopaedic Surgery.

A changing medical education environment

The Division’s move towards CBE and simulation has a lot to do with a changing clinical environment. Previously, medical residents in the traditional “time-spent” model were expected to acquire skills and experience by working on real clinical cases. The time-spent model has become increasingly impractical due to new medical resident work restrictions and a growing concern for patient safety and improved operating room efficiencies.

“Although the evaluation data is preliminary, we can assume that this approach will translate into improved patient care and safety,” said Dr. Nousiainen. “Trainees are demonstrating more competencies before they take care of patients in independent practice. This means that patient outcomes should improve.”

Dr. Tim Willett, Director of Research and Development for SIM-one – Ontario Simulation Network, said: “What the Division was able to achieve with simulation-enhanced training is quite remarkable. The Division’s competency-based approach effectively integrates simulation with traditional clinical and OR time to optimize residents’ learning in the limited clinical time. The results are a positive development for the medical education field.”

Competency-based education and simulation are now the norm at the University of Toronto’s Division of Orthopaedic Surgery. As a result of the model’s success, all Canadian specialty residency training programs will be required to begin implementing CBE by 2018.

Research for this article was conducted via interview with Dr. Nousiainen and through the following academic articles:

Reflections on competency-based education and training for surgical residentsJournal of Surgical Education. Sonnadara RR, Mui C, McQueen S, et al.

Three-year experience with an innovative, modular competency-based curriculum for orthopaedic trainingThe Journal of Bone & Joint Surgery. Ferguson PC, Kraemer W, Nousiainen M, et al.

Toronto orthopaedic boot camp III: examining the efficacy of student-regulated learning during an intensive, laboratory-based surgical skills courseSurgery. Sonnadara RR, Garbedian S, Safir O, et al.

Competency-based education: a new model for teaching orthopaedicsAmerican Academy of Orthopaedic Surgeons Instructional Course Lectures. Alman BA, Ferguson P, Kraemer W, et al.


About SIM-one

SIM-one—the Ontario Simulation Network—is a not-for-profit organization that connects the simulation community, facilities, resources and services across the Province of Ontario. SIM-one advocates for and advances simulated learning in health professions education for the benefit of patient care and patient safety. Supported in part by the Ministry of Health and Long-Term Care (MOHLTC), SIM-one’s vision is to further position Ontario as the global leader in healthcare simulation.