Unlock the future of orthopaedic residency training as Dr. Douglas W. Lundy sits down with Dr. J. Lawrence Marsh, a leading voice in the field and chair of the Department of Orthopedic Surgery at the University of Iowa Hospitals and Clinics. Dr. Marsh shares a treasure trove of insights on the paradigm shift from a time-based to a competency-based education system, already gaining momentum in countries like Canada, Australia, and the UK. Listen to Dr. Marsh's firsthand experience and wisdom on what these changes mean for the next generation of orthopaedic residents in the US and how they are set to revolutionize medical training.
Discover the intriguing challenges of granting more independence to exceptionally skilled surgical residents and how this can widen the competency gap between them and their peers. We explore the logistical and operational hurdles in transitioning to a competency-based training system and why a well-defined curriculum is critical. Organizations like the ACGME and orthopaedic boards are taking significant steps to implement this new framework, and we discuss the delicate balance needed to integrate competency-based attributes within the traditional time-based structure.
Stay ahead of the curve with the latest advancements in residency training, particularly through practice-based assessments and real-time evaluations using mobile technology. These innovations promise to significantly enhance skill acquisition and feedback, generating vast amounts of data to improve training standards. From basic models to cutting-edge VR simulations, we delve into the essential role of technology in preparing residents for complex surgical tasks. Finally, we contemplate the external forces driving rapid transformation in medical education, emphasizing the urgency for change within the next three years. Join us for an enlightening conversation that promises to reshape the future of orthopaedic education.
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Transcript
Episode Transcript
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Speaker 2 (00:22):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself reveals itself.
We will consider changes asthey occur in the domains of
(00:45):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthe podcast series.
Joining us today is Dr LarryMarsh.
Dr Marsh is a tenured professorand chair of the Department of
Orthopedic Surgery at theUniversity of Iowa Hospitals and
(01:06):
Clinics.
He received his bachelor'sdegree from Colgate University,
his medical degree from UpstateMedical Center in Syracuse, new
York, and trained in orthopedicsurgery at Boston University.
After completion of hisresidency, he served two years
as university lecturer inorthopedic surgery at Oxford
University in Oxford, england.
He was the president of theAmerican Board of Orthopedic
(01:28):
Surgery from 2015 to 2016, aswell as president of the
American Orthopedic Associationand the Mid-American Orthopedic
Association.
He's a member of manyprofessional organizations,
including the Orthopedic TraumaAssociation, american Academy of
Orthopedic Surgeons and theNational Board of Medical
Examiners.
He's past chair of theOrthopedic Residency Review
(01:50):
Committee of the AccreditationCouncil of the Graduate Medical
Education.
Dr Marshall's clinical practiceis devoted to orthopedic trauma
and adult reconstruction, andhe's developed techniques of
minimally invasive articularfracture surgery.
His research has focused onarticular fractures and
techniques of image analysis toassess the mechanical factors
(02:10):
leading to post-traumaticosteoarthritis.
His research has been funded bythe NIH, the OTA, the Arthritis
Foundation, the AO and the NBME.
He and his co-authors wererecipients of the 2011 OREF
Clinical Research Award fortheir work on post-traumatic
arthritis.
Today, dr Marsh and I willdiscuss how the future in
(02:33):
orthopedic surgery relates tochanges in resident education,
and I've got to know Larry wellthrough my time with him on the
board of the American Board ofOrthopedic Surgery, where he
focused a lot on this.
So, dr Marsh, welcome to thepodcast, sir.
Speaker 3 (02:49):
Doug thanks for having me and thanks for that
intro.
Speaker 2 (02:52):
Yes, sir, my pleasure .
So while we were on the boardtogether and I was the sole
private practice guy that reallyhad no clue to what y'all in
the depths of academia werediscussing really had no clue to
what y'all in the depths ofacademia were discussing you and
a number of other folks werereally discussing and talking
about the changes in residencyeducation and where this was all
(03:13):
headed, and that's very salientto the whole purpose behind
this podcast series.
So, in a nutshell, your vision.
Where do you think orthopedicresidency training is going as
the future continues to roll on?
Speaker 3 (03:29):
Well, doug, to cut it fairly quick, it isn't just
orthopedics.
I think all of graduate medicaleducation is moving in the
direction of competency-basededucation.
That does not mean in the US,in my opinion, away from
time-based education, and I cansort of explain the differences
(03:52):
as we get into it.
But I do think, led bycolleagues across the world, in
the English-speaking world, inthe Canadian system world, in
the English-speaking world, inthe Canadian system, the
Australian system and the UnitedKingdom, there have been pretty
strong shifts that the qualityof an individual resident should
(04:15):
be measured by reachingcompetency benchmarks rather
than some arbitrary piece oftime or time designation.
And you know, as you, you know,we are so embedded in it.
We all educated, we educate ourcurrent residents and they come
in as PGY1s and they expect,and we expect in orthopedics
(04:39):
that five years later theireducational program is done and
we do need to dictate paragraphsto say that they are ready to
practice general orthopedics andready to go to fellowships.
But the truth is, the realdriver of the end of their
education is time, and inorthopedics it is five years.
(05:02):
And if you look at the boardrequirements, it's dissected
into how many weeks you need todo each year and and we have
looked at that to be able toaccommodate various medical
leaves or maternity leaves orthings like that.
But basically it is still allyou're talking about how many
times, how much time, how manyweeks a year, and how many times
(05:23):
how much time, how many weeks ayear and how many years.
And again, those of us that inorthopedics we know what it is.
It's five plus one, it's fiveyears and one year of fellowship
, because the vast majority ofresidents are you should meet
and you know somebody needs todecide what those standards are
(05:54):
and then you need to decide howyou're going to measure whether
you've met them or not.
But you should meet thosecompetency standards to finish
training.
So that's sort of the bigpicture and you know that is
happening in orthopedics aroundthe pretty predominantly around
the English speaking world.
It's happening in Canada acrossall of graduate medical
(06:18):
education.
I don't know exactly where theystand now, but I think all
programs have had to move tocompetency standards and in this
country, in our graduatemedical education and in
orthopedics, most peopleinterested in education should
at least have a grasp on theseconcepts.
(06:40):
We aren't there, we're still ina time-based system, but we are
making steps towards thinkingabout how we can integrate
competency and, as you know, inyour years on the board, the
board and the educationcommittee on the board and the
overall board has been veryinterested in what its role is
in making that happen and I canalso talk about that if we want
(07:04):
to dive into that deeper.
Speaker 2 (07:06):
Sure, now in your time as AOA president, of course
you were on carousel so you gotto visit and you became friends
with all the presidents of theEnglish speaking orthopedic
organizations.
So to folks who are thinking,is this just you know, the board
or the academic folks justtrying to shake stuff up and do
something different To yourpoint, in your experience this
(07:29):
has already been rolled out to afurther degree across the
English speaking world.
Can you talk about that just alittle bit and also about what
you saw when you were onCarousel in terms of, or your
interactions with the otherorthopedic organization
presidents?
Speaker 3 (07:44):
Yeah, I can.
I can go there somewhat.
You know, I think the Torontoprogram in orthopedics was a
leader in really totallychanging the paradigm and mostly
eliminate timing.
I don't know if they completelyeliminated and changing their
(08:04):
large orthopedic educationalprogram to competency.
It was probably close to juststraddling the first and second
decade of the 2000s and they hadenough data in 2013 to put it
in the JBJS and, as I recall, alead article and I remember it
well because I got asked towrite an editorial about it and
(08:28):
it was really eye-opening atthat time, 10 or 11 years ago,
and you sort of looked at it.
You said you know this reallymakes sense and it's really
interesting that they are doingit.
I think in the UK for years it'sbeen modestly time variable.
There may be other things intheir system other than just
(08:50):
competency and assessments thatkeep trainees in posts and have
it be variable time when theymove on to be consultants.
And during my time on the AOAand in the year or two
afterwards, because I went backthere the year after I was on
the AOA, and in the year or twoafterwards, because I went back
there the year after I was onthe AOA, they were also.
(09:10):
It's the Australian AOA.
They're both AOAs.
They were heavily embraced intotrying to move their orthopedic
graduate medical education tocompetency-based and in the time
I spent in that country I wasvery impressed with their
efforts towards education andtheir dedication to try and move
(09:31):
it in that direction.
Speaker 2 (09:33):
Now you brought this up a little bit, but to really
clarify the issue, what exactlyis competency-based training
addressing that time-basededucation is lacking on?
You talked about it briefly,but to really just focus in on
it, what is the core issue thatthis is?
Fixing that our current systemis failing.
Speaker 3 (09:56):
Well, doug, I think we would all have to agree that
our residents, when they come,in when they train and when we
finish with them are variable.
They're variable in multipleways.
They're variable in how theyinteract with faculty.
They're variable in many, manythings.
(10:17):
But they are variable in theiroperative skills.
They're variable in theirknowledge.
They're variable in theirprofessional behaviors.
And you know, I do think we'recomfortable that most of them
get to a good endpoint.
Some of them are a struggle.
Anybody that's been ineducation struggles.
(10:40):
Some of them get there smoothlyand quickly and easily and of
course, those are the ones thatwe love because they can have
increasing independence towardsthe end of their training.
And you know one of my majorthemes, george, just in thinking
about this whole thing, that asthey get increasing
(11:02):
independence because they'rereally good, what happens to
them?
They get increasingindependence because they're
really good, what happens tothem?
They get better.
So to some extent you widen thegap between the gifted trainee
and the person that's strugglingmore because you give the
gifted trainee more graduatedresponsibility, more
(11:26):
independence.
Take it to the operating room.
You know who gets to do themost cases.
Who do you give the most ofyour case to?
Who do you not scrub and watchthem do the case?
The resident that's good.
Who do you take more of thecase away?
Who do you always scrub with?
(11:47):
The resident that has lessskills?
So you know, if you think aboutit that way, there are things
in our training paradigm thatwidens the skill gap or widens
the competency gap and I thinkto anybody that thinks about it
those things make sense.
And if you put that on it, youknow.
(12:10):
Do you say that that arbitraryamount of time again for us it's
five years is the right time torelease residents in
independent practice, or shouldthe person that was really good
have been released a year before?
You know why do we keep them inthe system as a worker?
(12:33):
Well, we keep them in becausethey are partially workers and
we pay them to do that and weneed that labor.
But if you step away from that,you say just in the educational
program, why should they stay?
And of course that's some ofthe challenges that we have in
our system of really movingfully to competency education.
(12:56):
Because they are partiallyworkers and we need them to work
and floating them in and outbased on competency standards
has its challenges.
And you know, I can at somepoint in this I can tell you
where I think it's going.
But I do think, if you can stepout of where we are and say,
(13:17):
does that make sense that ourgraduating residents should have
met standards rather than havemet some time criteria, it makes
sense and that at least forsome of our cohort it would be
good.
They don't need to stay anextra year, or they do need to
stay yet one more extra yearbecause they need to catch up
(13:42):
and do other things.
Speaker 2 (13:44):
So I could see the operational folks that are
suppose you have four residentsper year and each of them are on
three-month blocks.
And Dr Smith, she gets it.
She crushed adult recon, she'sgot it all figured out and she's
ready to move on.
But her next rotation would betrauma and Dr Jones, who's on
trauma, is just struggling toget through.
(14:04):
So you can't move him onbecause there's no place for her
to go there, because you'restill working with the one
that's more difficultoperationally.
How do you see this going outand how do other successful
programs who have done thisinternationally?
How do they make this work?
Speaker 3 (14:22):
Well, I can tell you what I think it will mean for us
.
I can't see in my career or thetruth is, in a career of
somebody 10 years behind me thatwe will eliminate time-based
training and I think for sort ofthe example you gave but you
(14:44):
can even talk it at a higherlevel Again who's going to pay
for residents that need to doextra years, right, how is the
work system going to deal withresidents that you've?
You know, say you have four, asyou said, and two of them are
great.
You're just going to let themgo in our system.
(15:06):
That isn't going to work, or atleast not with that 10-year
horizon.
I don't think it's going towork.
On the other hand, I think thereare important attributes of the
competency-based system and Ican tell you what I think about
those that can be layered onto atime-based system that will
(15:30):
improve our education, and Ithink those are relatively
easily within reach and, as youknow, our board has sort of
started to push some of thoseforward, of started to push some
(15:51):
of those forward and, in myopinion, things like the board
has done has to come from one ofthe organizations that can
require things, and there's twoorganizations One is the ACGME
and for orthopedics, theorthopedic RRC, and the second
is the board, because nobody isgoing to just open their arms
and say we're going to juststart to do this, or at least
relatively few.
(16:12):
They have to be required andour board has made steps in that
direction.
Speaker 2 (16:18):
So what are these attributes that you were talking
about that are present withincompetency-based, that could be
layered over time-based?
Speaker 3 (16:24):
So if you want to say that you should train to
competency, you need to ask thequestion competent in what?
Right?
And that means you have to havea curriculum.
My opinion, and orthopedics ina lot of ways over the years
that you and I have been in it,have resisted that concept a
(16:47):
little bit.
You know we've got a part oneboard exam.
You should immerse yourself inall the areas of orthopedics.
You don't want to confine yourknowledge acquisition.
And curriculum was almost a badword.
But the truth is if you say Iwant my resident to train until
they're competent, you have tosay okay, competent in what?
(17:10):
What do they need to do?
What skills do they need tohave?
What knowledge do they need tohave?
And I again, I think pushes inthe direction that there should
be some sort of curriculum ofwhat knowledge and skills they
(17:30):
need to acquire to be a goodgeneral orthopedist is a good
direction.
And, as you know, the board hasfocused its blueprint of the
part one exam and made it moreavailable and is wrestling with
an assessment-based skillscurriculum and is trying to make
(17:50):
steps in that direction.
And the RRC has broadened itsprocedural minimums, so now it's
gone from just 15 to I don'tknow the exact number they're
going to and about to roll out,and again, to me those things
start to approach being acurriculum and it makes sense to
(18:11):
me.
And then, once you have acurriculum, you say, okay, you
have to be competent in thesethings.
How do you know you'recompetent?
Well, you have to haveassessments and ideally, you
know you have some goodworkplace-based assessments, so
assessments of the residentsactually doing the activities
(18:33):
they need to do, whether it'ssurgical cases or whether it's
indicating a patient, or whetherit's in the emergency room or a
variety of things.
You have good assessments andthen, ideally, you start to move
the assessment of theirknowledge into residency
training rather than just at theend of residency training.
You know why should you waittill they're gone from training
(18:56):
and say now your knowledge isgood, or the four or five
percent of you is not?
Well, what then?
You know you're, you're outinto your training.
So I think both of those thingsthat are fundamental to
competency based training thatyou have to have a curriculum
competent in what?
And you have to haveassessments that you have
(19:19):
achieved those competence inthat curriculum are good things
and I think those can be layeredon to what remains a
fundamentally time-based programand if I understand what
Toronto is really doing, soagain, that's the a dozen years
(19:41):
or more blazing a trail in thisin a large orthopedic program,
blazing a trail in this in alarge orthopedic program.
I think they actually have afair amount of time that is
still in their competency-basedprogram that's 12 or 15 years
mature.
I don't want to speak too muchfor it because I'm not an expert
(20:01):
, but I think I've heard Markwho say that that, yeah, most of
ours are in whatever I thinkthey're also five years, but
they have a few that do this orthat.
I mean in our system.
Again, for the example youalready gave, floating in and
out is not going to be very easy, other than in unusual
(20:23):
circumstances, unusualcircumstances.
I also think a bettercurriculum and assessment of
that curriculum will helpprograms identify residents that
are struggling earlier andbetter and then hopefully with
the goal of remediation andsuccess at the end.
(20:45):
And again it just makes sensethat we should be able to do
these things better than what wedo.
So that's sort of my vision ofwhere it is going.
I think it was a pretty sharedvision across a lot of the board
and since you and I havestepped out of it.
You know that at least part ofthat vision the board has
(21:10):
embraced and has started torequire.
It has and again we can talkabout that a little bit if you
want and has a number ofprograms that have stepped into
some of these assessments andhas now required that for the
graduating class next year andfor the incoming class that they
(21:34):
would be required toparticipate.
So it is starting to happen andin this country it is making
orthopedics at least approachingbeing a leader in this sort of
steps toward competency and Ithink there is a fair amount of
(21:57):
looking with admiration at whatorthopedics is trying to do
through our board initiatives.
Speaker 2 (22:02):
Yeah, so you brought up some of the things that the
ABOS board was directing on thatand, as you said, both of us
have termed off of the board andyou started it.
I remember you and Ann VanHeese and some of the other
folks really dug in and got thisthing going.
What do you think the ABOS'scurrent requirements and
activities are regarding this?
Speaker 3 (22:24):
Well.
So their skills assessmentprogram is probably the most
mature.
They call it KSB.
I'll give Terry Peabody creditfor those terms knowledge,
skills and behavior and Terryshould be credited with also
pushing this initiative alongwith Anne, and it's sort of I
(22:47):
mean my look at those terms.
It takes the six competenciesthat we live under in ACGME and
Boyle puts them together suchthat it's a package of three,
which is a little bit easier.
So you should acquire knowledge, you should acquire skills and
you should have goodcommunication skills and
professional behavior.
(23:07):
So that's knowledge, skills andbehaviors.
The board, during our time,worked on initial initiatives in
all three of those areas andall three of those initiatives
still exist and have goneforward.
The skills one is the one thatis really making a big step.
(23:29):
So skills is practice-basedassessments, mobile phone,
optimized resident requests andevaluation of a real-time case
that they're doing.
Of a real-time case thatthey're doing.
(23:49):
We have an OP scoring form thatthen comes to the faculty on
their phone and it literally isa 30-second job to fill out.
Again, as close to real-timeassessment of performance as you
can get.
You can also dictate or type informative feedback in a type
inbox and to me this is allnothing but good.
And as the residents acquiremultiple assessments, it starts
(24:14):
to be the level of pilot,leading to publication in JBGS,
leading to more and morepromotion at meetings, leading
to, I don't know, roughly halfof the programs or maybe a
little bit less, embracing this.
(24:37):
And the board, I believe at itslast fall meeting, has required
that they were going to mandatethis.
So it's going to go fromelective embracement to it will
be mandated.
And again, neither you or I areon the latest requirements, but
I think, knowing it and myresidency, that a year from now
(25:02):
the PGY-5s in that year willneed to accumulate a couple of
assessments a week for theiryear in the PGY-5, adding up to
80 years or some assessmentslike that.
And the PGY-1s will need tostart as interns, interns
(25:22):
getting a small number ofassessments on their orthopedic
rotations and then, as they goto two, three, four and five.
So it will be required that youhave to get some assessments
and that you will not bepermitted to sit, for your part,
one aboard if you haven't donethat.
And then my vision and Ihaven't heard the inner working
(25:44):
of the board, but I have talkedto John Harris is as it becomes
required in all programs aroundthe country.
There will start to be lots andlots of data produced.
And as lots of data is produced, you'll then be able to dissect
things out like whichprocedures and how many
(26:08):
procedures, which year, and whatdoes the average PGY-3 get to
in ankle fracture, for instance,and what does the bottom 10% of
PGY-3s get to an ankle fracture, how many?
And then what assessment levelare they getting?
(26:28):
And once you start to have thatdata in thousands and thousands
and thousands, you could startto raise your requirement higher
.
For instance, you could pickankle fracture and you could say
you know as a PGY-1, nothing'srequired.
As a 2, you should say you knowas a PGY1, nothing's required.
As a two, you should have youknow who knows four to six
(26:49):
exposures to ankle fracture.
And as a three, you shouldstart to reach some level.
You know, maybe not taking theindependent practice, able to be
on his or her own box, but thatyou should start to reach some
level.
And then you could also decidewell, what else should it be in
trauma other than ankle fracture?
(27:10):
That isn't enough.
So you could pick six or eightthings and if you have a lot of
data you could start to do thosewith a feeling that what you
would further require is basedon good information and data.
So how long it'll take to gothere I don't know, but once
it's required, a lot of datawill come quickly.
Speaker 2 (27:33):
There's also been a lot of work on skill simulation
and assessment throughsimulation, which much more
reasonably standardizes theactual activity across different
platforms.
Right, I think you wereextensively involved in that too
.
Where do you see that going inthe future?
Speaker 3 (27:50):
Well, we just did a symposium at Cord AOA last
Saturday morning on thatparticular topic.
So the board when I first cameon the board, I was fortunate
enough to be involved with thatand the board and the RRC got
pretty deep into simulationconsultancies.
With general surgery, we werefelt to be modestly behind or
(28:13):
quite behind in orthopedics andthe board and the RRC stepped up
to the 2013 programrequirements that required a
laboratory-based skills trainingprogram for PGY-1.
Having been on the podium someat that time there was a modest
amount of pushback typicalunfunded mandate and that sort
(28:36):
of thing but I think most,looking back on it, would say
that it was the right thing todo.
Since that time, the board hascontinued to look at it.
It's continued to sponsor thinktanks and symposium.
It has actually funded threerelatively large grants.
It's brought the grantrecipients together to look at
(28:57):
what they're doing and I thinkthe board has just slightly
hesitated on making anotherrequirement step in simulation.
So, while simulations haveadvanced over the last 10 years,
there's some pretty slickthings.
Now there are programs that areusing a number of these slick
(29:19):
things.
There's a lot of computersinvolved.
So it isn't just sawbones andcadaveric dissections.
Vr is coming.
You know exactly where itstands in the hierarchy, but it
gets better all the time and itis coming.
You know, it's my belief that totake another big step to
(29:42):
nationally moving it forward ithas to be required Again because
it costs money and it takestime.
Our residents are so busy inthe operating room.
But I do think back to you theorigin of your question how does
this advance the whole cause ofcompetency-based training?
We would all agree we have ahighly technically skilled
(30:06):
profession.
We would all agree that itisn't any easier to let junior
residents be operating on ourpatients than what it used to be
.
Pressures for time and billingand moving things along and all
of those types of things, aswell as quality and safety, and
therefore advancing junior levellearners on relatively simple,
(30:29):
inexpensive simulations in thelab rather than having them be
retractor holders as secondassistants in the operating room
makes a ton of sense.
And then when they come to youas a PGY-3, they are more ready
to go.
They are already more skilled.
You know those are allaspirational things of where we
(30:50):
would like to be, I think, otherthan simulations advanced in
some programs.
For instance, on the symposiumwas the Penn State group, robert
Gallo, and you know, andthey've done a lot of simulated
patient-based simulations.
So to move out of the technicalskills and move into, how do
you get your residents to begood at informed consent and
(31:13):
communicate well and deal withchallenging interactions and all
those kind of things that youkind of learn on the job and
some learn it better than others.
So, anyway, lots of interestingthings going on in pockets.
But to really widely changethings they have to be required
and I think at some point theboard will step up to that.
Speaker 2 (31:34):
Are there other parts of technology that you see
impacting resident education inthe future?
Speaker 3 (31:41):
Oh, I don't know.
You know, doug, there's allsorts of AI things and stuff
that are all over the news, andyou know, ai being able to score
in the 65th percentile and OITEexams, and you know, aren't
these tremendous values foreducation?
I don't know if I have a realsquare vision.
(32:03):
Do it Exactly how those thingswill advance to education?
(32:28):
I don't know.
I mean, to some extent you'vegot to put the knowledge and
skills in your brain.
Ai can't do it for you, so Idon't know.
That's sort of a quick thought.
Speaker 2 (32:38):
But to summarize what you were saying, within the
next 15 to 20 years we'll movecloser to competency-based
education, having to figure outthe whole timing basis of it and
how that affects fellowshipsand jobs and everything else
afterwards, or lengthening folksthat get there, the skills
assessment and, of course, thesimulation moving along as well
(32:59):
as other technology.
There's a lot going on in thatarea.
Speaker 3 (33:02):
Yeah, and I'll just mention one other, doug, that
steps directly out of the areaof education but could impact it
big time is money.
Oh yeah, so if the governmentpulled money out of resident
education because of course, aswe know, the government mostly
(33:24):
supports the resident salariesnot exclusively, but mostly if
they pulled it back or got moreinvolved in some way or another
and, for instance, asked thequestion do you really need to
train orthopedic residents forfive plus one?
That would change things in ahurry.
(33:45):
Oh yeah.
So that would you know.
For instance, if you were goingto have to turn five plus one
into three plus two.
Or you know you're training atotally subspecialized workforce
, why do they have to do fiveyears of general orthopedics?
And that would lead to tons ofarguments.
(34:07):
But if you pulled money out ofit, we would figure out how to
change it in a hurry and itwould force a curriculum big
time.
Okay, but only got three years.
What do they need to accomplishin three years?
And then, have they reallyaccomplished it?
And then get them off for twoyears into their subspecialty
(34:28):
work.
I mean, I think those thingscould happen.
I don't think we as educatorswill make them happen, but if
things happen with thegovernment, either from money
and training or frommaldistribution of workforce and
some of the healthcarechallenges that we face, these
(34:49):
things could happen.
Speaker 2 (34:50):
That is very well said because that to your point
and you said this multiple timesis that it's not just the
innovation within the sector,but it's the external forces
saying you have to move in thisdirection.
That will really impact changemore quickly.
Speaker 3 (35:03):
Totally agree.
Speaker 2 (35:04):
Well, this has been absolutely enlightening for me.
Great to talk again with you,larry, and I really appreciate
your insight on this.
As I said, I got to sit in theseat and listen to you and Terry
and Ann and as well as othersApril and others talk about
these things when I was stilltrying to learn a lot about it,
and I'm glad that we were ableto share this with the listeners
(35:25):
to the AOA podcast series.
So, dr Marsh, thank you forbeing on the podcast, sir.
Speaker 3 (35:29):
Doug, thanks for having me.
I enjoy chatting about thesethings.
They're really interesting.
Speaker 2 (35:35):
Yes, sir, and I look forward to other speakers and
engaging with y'all again on theAOA Futures in Orthopedic
Surgery Podcast Series.
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself reveals itself.
We will consider changes asthey occur in the domains of
(00:45):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthe podcast series.
Joining us today is Dr LarryMarsh.
Dr Marsh is a tenured professorand chair of the Department of
Orthopedic Surgery at theUniversity of Iowa Hospitals and
(01:06):
Clinics.
He received his bachelor'sdegree from Colgate University,
his medical degree from UpstateMedical Center in Syracuse, new
York, and trained in orthopedicsurgery at Boston University.
After completion of hisresidency, he served two years
as university lecturer inorthopedic surgery at Oxford
University in Oxford, england.
He was the president of theAmerican Board of Orthopedic
(01:28):
Surgery from 2015 to 2016, aswell as president of the
American Orthopedic Associationand the Mid-American Orthopedic
Association.
He's a member of manyprofessional organizations,
including the Orthopedic TraumaAssociation, american Academy of
Orthopedic Surgeons and theNational Board of Medical
Examiners.
He's past chair of theOrthopedic Residency Review
(01:50):
Committee of the AccreditationCouncil of the Graduate Medical
Education.
Dr Marshall's clinical practiceis devoted to orthopedic trauma
and adult reconstruction, andhe's developed techniques of
minimally invasive articularfracture surgery.
His research has focused onarticular fractures and
techniques of image analysis toassess the mechanical factors
(02:10):
leading to post-traumaticosteoarthritis.
His research has been funded bythe NIH, the OTA, the Arthritis
Foundation, the AO and the NBME.
He and his co-authors wererecipients of the 2011 OREF
Clinical Research Award fortheir work on post-traumatic
arthritis.
Today, dr Marsh and I willdiscuss how the future in
(02:33):
orthopedic surgery relates tochanges in resident education,
and I've got to know Larry wellthrough my time with him on the
board of the American Board ofOrthopedic Surgery, where he
focused a lot on this.
So, dr Marsh, welcome to thepodcast, sir.
Speaker 3 (02:49):
Doug thanks for having me and thanks for that
intro.
Speaker 2 (02:52):
Yes, sir, my pleasure .
So while we were on the boardtogether and I was the sole
private practice guy that reallyhad no clue to what y'all in
the depths of academia werediscussing really had no clue to
what y'all in the depths ofacademia were discussing you and
a number of other folks werereally discussing and talking
about the changes in residencyeducation and where this was all
(03:13):
headed, and that's very salientto the whole purpose behind
this podcast series.
So, in a nutshell, your vision.
Where do you think orthopedicresidency training is going as
the future continues to roll on?
Speaker 3 (03:29):
Well, doug, to cut it fairly quick, it isn't just
orthopedics.
I think all of graduate medicaleducation is moving in the
direction of competency-basededucation.
That does not mean in the US,in my opinion, away from
time-based education, and I cansort of explain the differences
(03:52):
as we get into it.
But I do think, led bycolleagues across the world, in
the English-speaking world, inthe Canadian system world, in
the English-speaking world, inthe Canadian system, the
Australian system and the UnitedKingdom, there have been pretty
strong shifts that the qualityof an individual resident should
(04:15):
be measured by reachingcompetency benchmarks rather
than some arbitrary piece oftime or time designation.
And you know, as you, you know,we are so embedded in it.
We all educated, we educate ourcurrent residents and they come
in as PGY1s and they expect,and we expect in orthopedics
(04:39):
that five years later theireducational program is done and
we do need to dictate paragraphsto say that they are ready to
practice general orthopedics andready to go to fellowships.
But the truth is, the realdriver of the end of their
education is time, and inorthopedics it is five years.
(05:02):
And if you look at the boardrequirements, it's dissected
into how many weeks you need todo each year and and we have
looked at that to be able toaccommodate various medical
leaves or maternity leaves orthings like that.
But basically it is still allyou're talking about how many
times, how much time, how manyweeks a year, and how many times
(05:23):
how much time, how many weeks ayear and how many years.
And again, those of us that inorthopedics we know what it is.
It's five plus one, it's fiveyears and one year of fellowship
, because the vast majority ofresidents are you should meet
and you know somebody needs todecide what those standards are
(05:54):
and then you need to decide howyou're going to measure whether
you've met them or not.
But you should meet thosecompetency standards to finish
training.
So that's sort of the bigpicture and you know that is
happening in orthopedics aroundthe pretty predominantly around
the English speaking world.
It's happening in Canada acrossall of graduate medical
(06:18):
education.
I don't know exactly where theystand now, but I think all
programs have had to move tocompetency standards and in this
country, in our graduatemedical education and in
orthopedics, most peopleinterested in education should
at least have a grasp on theseconcepts.
(06:40):
We aren't there, we're still ina time-based system, but we are
making steps towards thinkingabout how we can integrate
competency and, as you know, inyour years on the board, the
board and the educationcommittee on the board and the
overall board has been veryinterested in what its role is
in making that happen and I canalso talk about that if we want
(07:04):
to dive into that deeper.
Speaker 2 (07:06):
Sure, now in your time as AOA president, of course
you were on carousel so you gotto visit and you became friends
with all the presidents of theEnglish speaking orthopedic
organizations.
So to folks who are thinking,is this just you know, the board
or the academic folks justtrying to shake stuff up and do
something different To yourpoint, in your experience this
(07:29):
has already been rolled out to afurther degree across the
English speaking world.
Can you talk about that just alittle bit and also about what
you saw when you were onCarousel in terms of, or your
interactions with the otherorthopedic organization
presidents?
Speaker 3 (07:44):
Yeah, I can.
I can go there somewhat.
You know, I think the Torontoprogram in orthopedics was a
leader in really totallychanging the paradigm and mostly
eliminate timing.
I don't know if they completelyeliminated and changing their
(08:04):
large orthopedic educationalprogram to competency.
It was probably close to juststraddling the first and second
decade of the 2000s and they hadenough data in 2013 to put it
in the JBJS and, as I recall, alead article and I remember it
well because I got asked towrite an editorial about it and
(08:28):
it was really eye-opening atthat time, 10 or 11 years ago,
and you sort of looked at it.
You said you know this reallymakes sense and it's really
interesting that they are doingit.
I think in the UK for years it'sbeen modestly time variable.
There may be other things intheir system other than just
(08:50):
competency and assessments thatkeep trainees in posts and have
it be variable time when theymove on to be consultants.
And during my time on the AOAand in the year or two
afterwards, because I went backthere the year after I was on
the AOA, and in the year or twoafterwards, because I went back
there the year after I was onthe AOA, they were also.
(09:10):
It's the Australian AOA.
They're both AOAs.
They were heavily embraced intotrying to move their orthopedic
graduate medical education tocompetency-based and in the time
I spent in that country I wasvery impressed with their
efforts towards education andtheir dedication to try and move
(09:31):
it in that direction.
Speaker 2 (09:33):
Now you brought this up a little bit, but to really
clarify the issue, what exactlyis competency-based training
addressing that time-basededucation is lacking on?
You talked about it briefly,but to really just focus in on
it, what is the core issue thatthis is?
Fixing that our current systemis failing.
Speaker 3 (09:56):
Well, doug, I think we would all have to agree that
our residents, when they come,in when they train and when we
finish with them are variable.
They're variable in multipleways.
They're variable in how theyinteract with faculty.
They're variable in many, manythings.
(10:17):
But they are variable in theiroperative skills.
They're variable in theirknowledge.
They're variable in theirprofessional behaviors.
And you know, I do think we'recomfortable that most of them
get to a good endpoint.
Some of them are a struggle.
Anybody that's been ineducation struggles.
(10:40):
Some of them get there smoothlyand quickly and easily and of
course, those are the ones thatwe love because they can have
increasing independence towardsthe end of their training.
And you know one of my majorthemes, george, just in thinking
about this whole thing, that asthey get increasing
(11:02):
independence because they'rereally good, what happens to
them?
They get increasingindependence because they're
really good, what happens tothem?
They get better.
So to some extent you widen thegap between the gifted trainee
and the person that's strugglingmore because you give the
gifted trainee more graduatedresponsibility, more
(11:26):
independence.
Take it to the operating room.
You know who gets to do themost cases.
Who do you give the most ofyour case to?
Who do you not scrub and watchthem do the case?
The resident that's good.
Who do you take more of thecase away?
Who do you always scrub with?
(11:47):
The resident that has lessskills?
So you know, if you think aboutit that way, there are things
in our training paradigm thatwidens the skill gap or widens
the competency gap and I thinkto anybody that thinks about it
those things make sense.
And if you put that on it, youknow.
(12:10):
Do you say that that arbitraryamount of time again for us it's
five years is the right time torelease residents in
independent practice, or shouldthe person that was really good
have been released a year before?
You know why do we keep them inthe system as a worker?
(12:33):
Well, we keep them in becausethey are partially workers and
we pay them to do that and weneed that labor.
But if you step away from that,you say just in the educational
program, why should they stay?
And of course that's some ofthe challenges that we have in
our system of really movingfully to competency education.
(12:56):
Because they are partiallyworkers and we need them to work
and floating them in and outbased on competency standards
has its challenges.
And you know, I can at somepoint in this I can tell you
where I think it's going.
But I do think, if you can stepout of where we are and say,
(13:17):
does that make sense that ourgraduating residents should have
met standards rather than havemet some time criteria, it makes
sense and that at least forsome of our cohort it would be
good.
They don't need to stay anextra year, or they do need to
stay yet one more extra yearbecause they need to catch up
(13:42):
and do other things.
Speaker 2 (13:44):
So I could see the operational folks that are
suppose you have four residentsper year and each of them are on
three-month blocks.
And Dr Smith, she gets it.
She crushed adult recon, she'sgot it all figured out and she's
ready to move on.
But her next rotation would betrauma and Dr Jones, who's on
trauma, is just struggling toget through.
(14:04):
So you can't move him onbecause there's no place for her
to go there, because you'restill working with the one
that's more difficultoperationally.
How do you see this going outand how do other successful
programs who have done thisinternationally?
How do they make this work?
Speaker 3 (14:22):
Well, I can tell you what I think it will mean for us
.
I can't see in my career or thetruth is, in a career of
somebody 10 years behind me thatwe will eliminate time-based
training and I think for sort ofthe example you gave but you
(14:44):
can even talk it at a higherlevel Again who's going to pay
for residents that need to doextra years, right, how is the
work system going to deal withresidents that you've?
You know, say you have four, asyou said, and two of them are
great.
You're just going to let themgo in our system.
(15:06):
That isn't going to work, or atleast not with that 10-year
horizon.
I don't think it's going towork.
On the other hand, I think thereare important attributes of the
competency-based system and Ican tell you what I think about
those that can be layered onto atime-based system that will
(15:30):
improve our education, and Ithink those are relatively
easily within reach and, as youknow, our board has sort of
started to push some of thoseforward, of started to push some
(15:51):
of those forward and, in myopinion, things like the board
has done has to come from one ofthe organizations that can
require things, and there's twoorganizations One is the ACGME
and for orthopedics, theorthopedic RRC, and the second
is the board, because nobody isgoing to just open their arms
and say we're going to juststart to do this, or at least
relatively few.
(16:12):
They have to be required andour board has made steps in that
direction.
Speaker 2 (16:18):
So what are these attributes that you were talking
about that are present withincompetency-based, that could be
layered over time-based?
Speaker 3 (16:24):
So if you want to say that you should train to
competency, you need to ask thequestion competent in what?
Right?
And that means you have to havea curriculum.
My opinion, and orthopedics ina lot of ways over the years
that you and I have been in it,have resisted that concept a
(16:47):
little bit.
You know we've got a part oneboard exam.
You should immerse yourself inall the areas of orthopedics.
You don't want to confine yourknowledge acquisition.
And curriculum was almost a badword.
But the truth is if you say Iwant my resident to train until
they're competent, you have tosay okay, competent in what?
(17:10):
What do they need to do?
What skills do they need tohave?
What knowledge do they need tohave?
And I again, I think pushes inthe direction that there should
be some sort of curriculum ofwhat knowledge and skills they
(17:30):
need to acquire to be a goodgeneral orthopedist is a good
direction.
And, as you know, the board hasfocused its blueprint of the
part one exam and made it moreavailable and is wrestling with
an assessment-based skillscurriculum and is trying to make
(17:50):
steps in that direction.
And the RRC has broadened itsprocedural minimums, so now it's
gone from just 15 to I don'tknow the exact number they're
going to and about to roll out,and again, to me those things
start to approach being acurriculum and it makes sense to
(18:11):
me.
And then, once you have acurriculum, you say, okay, you
have to be competent in thesethings.
How do you know you'recompetent?
Well, you have to haveassessments and ideally, you
know you have some goodworkplace-based assessments, so
assessments of the residentsactually doing the activities
(18:33):
they need to do, whether it'ssurgical cases or whether it's
indicating a patient, or whetherit's in the emergency room or a
variety of things.
You have good assessments andthen, ideally, you start to move
the assessment of theirknowledge into residency
training rather than just at theend of residency training.
You know why should you waittill they're gone from training
(18:56):
and say now your knowledge isgood, or the four or five
percent of you is not?
Well, what then?
You know you're, you're outinto your training.
So I think both of those thingsthat are fundamental to
competency based training thatyou have to have a curriculum
competent in what?
And you have to haveassessments that you have
(19:19):
achieved those competence inthat curriculum are good things
and I think those can be layeredon to what remains a
fundamentally time-based programand if I understand what
Toronto is really doing, soagain, that's the a dozen years
(19:41):
or more blazing a trail in thisin a large orthopedic program,
blazing a trail in this in alarge orthopedic program.
I think they actually have afair amount of time that is
still in their competency-basedprogram that's 12 or 15 years
mature.
I don't want to speak too muchfor it because I'm not an expert
(20:01):
, but I think I've heard Markwho say that that, yeah, most of
ours are in whatever I thinkthey're also five years, but
they have a few that do this orthat.
I mean in our system.
Again, for the example youalready gave, floating in and
out is not going to be very easy, other than in unusual
(20:23):
circumstances, unusualcircumstances.
I also think a bettercurriculum and assessment of
that curriculum will helpprograms identify residents that
are struggling earlier andbetter and then hopefully with
the goal of remediation andsuccess at the end.
(20:45):
And again it just makes sensethat we should be able to do
these things better than what wedo.
So that's sort of my vision ofwhere it is going.
I think it was a pretty sharedvision across a lot of the board
and since you and I havestepped out of it.
You know that at least part ofthat vision the board has
(21:10):
embraced and has started torequire.
It has and again we can talkabout that a little bit if you
want and has a number ofprograms that have stepped into
some of these assessments andhas now required that for the
graduating class next year andfor the incoming class that they
(21:34):
would be required toparticipate.
So it is starting to happen andin this country it is making
orthopedics at least approachingbeing a leader in this sort of
steps toward competency and Ithink there is a fair amount of
(21:57):
looking with admiration at whatorthopedics is trying to do
through our board initiatives.
Speaker 2 (22:02):
Yeah, so you brought up some of the things that the
ABOS board was directing on thatand, as you said, both of us
have termed off of the board andyou started it.
I remember you and Ann VanHeese and some of the other
folks really dug in and got thisthing going.
What do you think the ABOS'scurrent requirements and
activities are regarding this?
Speaker 3 (22:24):
Well.
So their skills assessmentprogram is probably the most
mature.
They call it KSB.
I'll give Terry Peabody creditfor those terms knowledge,
skills and behavior and Terryshould be credited with also
pushing this initiative alongwith Anne, and it's sort of I
(22:47):
mean my look at those terms.
It takes the six competenciesthat we live under in ACGME and
Boyle puts them together suchthat it's a package of three,
which is a little bit easier.
So you should acquire knowledge, you should acquire skills and
you should have goodcommunication skills and
professional behavior.
(23:07):
So that's knowledge, skills andbehaviors.
The board, during our time,worked on initial initiatives in
all three of those areas andall three of those initiatives
still exist and have goneforward.
The skills one is the one thatis really making a big step.
(23:29):
So skills is practice-basedassessments, mobile phone,
optimized resident requests andevaluation of a real-time case
that they're doing.
Of a real-time case thatthey're doing.
(23:49):
We have an OP scoring form thatthen comes to the faculty on
their phone and it literally isa 30-second job to fill out.
Again, as close to real-timeassessment of performance as you
can get.
You can also dictate or type informative feedback in a type
inbox and to me this is allnothing but good.
And as the residents acquiremultiple assessments, it starts
(24:14):
to be the level of pilot,leading to publication in JBGS,
leading to more and morepromotion at meetings, leading
to, I don't know, roughly halfof the programs or maybe a
little bit less, embracing this.
(24:37):
And the board, I believe at itslast fall meeting, has required
that they were going to mandatethis.
So it's going to go fromelective embracement to it will
be mandated.
And again, neither you or I areon the latest requirements, but
I think, knowing it and myresidency, that a year from now
(25:02):
the PGY-5s in that year willneed to accumulate a couple of
assessments a week for theiryear in the PGY-5, adding up to
80 years or some assessmentslike that.
And the PGY-1s will need tostart as interns, interns
(25:22):
getting a small number ofassessments on their orthopedic
rotations and then, as they goto two, three, four and five.
So it will be required that youhave to get some assessments
and that you will not bepermitted to sit, for your part,
one aboard if you haven't donethat.
And then my vision and Ihaven't heard the inner working
(25:44):
of the board, but I have talkedto John Harris is as it becomes
required in all programs aroundthe country.
There will start to be lots andlots of data produced.
And as lots of data is produced, you'll then be able to dissect
things out like whichprocedures and how many
(26:08):
procedures, which year, and whatdoes the average PGY-3 get to
in ankle fracture, for instance,and what does the bottom 10% of
PGY-3s get to an ankle fracture, how many?
And then what assessment levelare they getting?
(26:28):
And once you start to have thatdata in thousands and thousands
and thousands, you could startto raise your requirement higher
.
For instance, you could pickankle fracture and you could say
you know as a PGY-1, nothing'srequired.
As a 2, you should say you knowas a PGY1, nothing's required.
As a two, you should have youknow who knows four to six
(26:49):
exposures to ankle fracture.
And as a three, you shouldstart to reach some level.
You know, maybe not taking theindependent practice, able to be
on his or her own box, but thatyou should start to reach some
level.
And then you could also decidewell, what else should it be in
trauma other than ankle fracture?
(27:10):
That isn't enough.
So you could pick six or eightthings and if you have a lot of
data you could start to do thosewith a feeling that what you
would further require is basedon good information and data.
So how long it'll take to gothere I don't know, but once
it's required, a lot of datawill come quickly.
Speaker 2 (27:33):
There's also been a lot of work on skill simulation
and assessment throughsimulation, which much more
reasonably standardizes theactual activity across different
platforms.
Right, I think you wereextensively involved in that too
.
Where do you see that going inthe future?
Speaker 3 (27:50):
Well, we just did a symposium at Cord AOA last
Saturday morning on thatparticular topic.
So the board when I first cameon the board, I was fortunate
enough to be involved with thatand the board and the RRC got
pretty deep into simulationconsultancies.
With general surgery, we werefelt to be modestly behind or
(28:13):
quite behind in orthopedics andthe board and the RRC stepped up
to the 2013 programrequirements that required a
laboratory-based skills trainingprogram for PGY-1.
Having been on the podium someat that time there was a modest
amount of pushback typicalunfunded mandate and that sort
(28:36):
of thing but I think most,looking back on it, would say
that it was the right thing todo.
Since that time, the board hascontinued to look at it.
It's continued to sponsor thinktanks and symposium.
It has actually funded threerelatively large grants.
It's brought the grantrecipients together to look at
(28:57):
what they're doing and I thinkthe board has just slightly
hesitated on making anotherrequirement step in simulation.
So, while simulations haveadvanced over the last 10 years,
there's some pretty slickthings.
Now there are programs that areusing a number of these slick
(29:19):
things.
There's a lot of computersinvolved.
So it isn't just sawbones andcadaveric dissections.
Vr is coming.
You know exactly where itstands in the hierarchy, but it
gets better all the time and itis coming.
You know, it's my belief that totake another big step to
(29:42):
nationally moving it forward ithas to be required Again because
it costs money and it takestime.
Our residents are so busy inthe operating room.
But I do think back to you theorigin of your question how does
this advance the whole cause ofcompetency-based training?
We would all agree we have ahighly technically skilled
(30:06):
profession.
We would all agree that itisn't any easier to let junior
residents be operating on ourpatients than what it used to be
.
Pressures for time and billingand moving things along and all
of those types of things, aswell as quality and safety, and
therefore advancing junior levellearners on relatively simple,
(30:29):
inexpensive simulations in thelab rather than having them be
retractor holders as secondassistants in the operating room
makes a ton of sense.
And then when they come to youas a PGY-3, they are more ready
to go.
They are already more skilled.
You know those are allaspirational things of where we
(30:50):
would like to be, I think, otherthan simulations advanced in
some programs.
For instance, on the symposiumwas the Penn State group, robert
Gallo, and you know, andthey've done a lot of simulated
patient-based simulations.
So to move out of the technicalskills and move into, how do
you get your residents to begood at informed consent and
(31:13):
communicate well and deal withchallenging interactions and all
those kind of things that youkind of learn on the job and
some learn it better than others.
So, anyway, lots of interestingthings going on in pockets.
But to really widely changethings they have to be required
and I think at some point theboard will step up to that.
Speaker 2 (31:34):
Are there other parts of technology that you see
impacting resident education inthe future?
Speaker 3 (31:41):
Oh, I don't know.
You know, doug, there's allsorts of AI things and stuff
that are all over the news, andyou know, ai being able to score
in the 65th percentile and OITEexams, and you know, aren't
these tremendous values foreducation?
I don't know if I have a realsquare vision.
(32:03):
Do it Exactly how those thingswill advance to education?
(32:28):
I don't know.
I mean, to some extent you'vegot to put the knowledge and
skills in your brain.
Ai can't do it for you, so Idon't know.
That's sort of a quick thought.
Speaker 2 (32:38):
But to summarize what you were saying, within the
next 15 to 20 years we'll movecloser to competency-based
education, having to figure outthe whole timing basis of it and
how that affects fellowshipsand jobs and everything else
afterwards, or lengthening folksthat get there, the skills
assessment and, of course, thesimulation moving along as well
(32:59):
as other technology.
There's a lot going on in thatarea.
Speaker 3 (33:02):
Yeah, and I'll just mention one other, doug, that
steps directly out of the areaof education but could impact it
big time is money.
Oh yeah, so if the governmentpulled money out of resident
education because of course, aswe know, the government mostly
(33:24):
supports the resident salariesnot exclusively, but mostly if
they pulled it back or got moreinvolved in some way or another
and, for instance, asked thequestion do you really need to
train orthopedic residents forfive plus one?
That would change things in ahurry.
(33:45):
Oh yeah.
So that would you know.
For instance, if you were goingto have to turn five plus one
into three plus two.
Or you know you're training atotally subspecialized workforce
, why do they have to do fiveyears of general orthopedics?
And that would lead to tons ofarguments.
(34:07):
But if you pulled money out ofit, we would figure out how to
change it in a hurry and itwould force a curriculum big
time.
Okay, but only got three years.
What do they need to accomplishin three years?
And then, have they reallyaccomplished it?
And then get them off for twoyears into their subspecialty
(34:28):
work.
I mean, I think those thingscould happen.
I don't think we as educatorswill make them happen, but if
things happen with thegovernment, either from money
and training or frommaldistribution of workforce and
some of the healthcarechallenges that we face, these
(34:49):
things could happen.
Speaker 2 (34:50):
That is very well said because that to your point
and you said this multiple timesis that it's not just the
innovation within the sector,but it's the external forces
saying you have to move in thisdirection.
That will really impact changemore quickly.
Speaker 3 (35:03):
Totally agree.
Speaker 2 (35:04):
Well, this has been absolutely enlightening for me.
Great to talk again with you,larry, and I really appreciate
your insight on this.
As I said, I got to sit in theseat and listen to you and Terry
and Ann and as well as othersApril and others talk about
these things when I was stilltrying to learn a lot about it,
and I'm glad that we were ableto share this with the listeners
(35:25):
to the AOA podcast series.
So, dr Marsh, thank you forbeing on the podcast, sir.
Speaker 3 (35:29):
Doug, thanks for having me.
I enjoy chatting about thesethings.
They're really interesting.
Speaker 2 (35:35):
Yes, sir, and I look forward to other speakers and
engaging with y'all again on theAOA Futures in Orthopedic
Surgery Podcast Series.
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