How to develop and maintain a didactic schedule in a surgery residency

A. Alfred Chahine, MD, FACS, Patrick G. Jackson, MD,
Vinod Narra, MD, FACS, and Stephen R. T. Evans, MD, FACS

The responsibility to develop an effective and enriching didactic schedule is one of the most challenging tasks a program director faces. It is essential that residents are provided with a robust curriculum to complement their clinical experience. However, multiple challenges exist. In the next few paragraphs, we would like to share with you our approach in the department of surgery at Georgetown University Medical Center. We will discuss the challenges we faced and the solutions we came up with. We will also describe the shortcomings and pitfalls that we discovered in some of the solutions we used. The hurdles and proposed answers discussed below are presented randomly and not in any hierarchical order since we feel that these elements are interconnected like cogs in a wheel.

The 80-hour workweek limit
With the institution of the 80 hours per week work-hour limit, the number of residents available to attend conferences is seriously curtailed. In the past, evening conferences were a staple of many surgical programs primarily because residents and faculty were commonly available during that time after a day in the OR. However, in this era of work-hour restriction, this is no longer practical. Conferences had to be switched to a morning time to allow post-call residents to leave and be in compliance with the work-hour restriction. To minimize disruption of the operative schedule, we chose to consolidate all our required didactic sessions on one morning each week, which was designated as our educational day. All residents are required to be present on that morning even if they are rotating at affiliated institutions. Only emergency cases are scheduled on that morning. Nursing stations and other consulting services are informed of the unavailability of the residents except for life threatening situations and are asked to direct inquiries to attendings during that morning. Measures such as these obviously require the full support of the chairman of the department but reflect a deep and unwavering commitment to resident education.

In addition, specialty conferences are maintained by individual services, which are usually held for one or two hours in the afternoon. Only the residents on that particular service are expected to attend those meetings.

Consistency and sustainability
Designing the conference schedule was the easy part. The effort to sustain it weekly throughout the year with full faculty and resident participation and with minimal cancellation and disruption was a challenge we faced the first year we reformed our curriculum (2003-2004). The Graduate Surgical Education Committee, which consists of representatives from all the surgical divisions, was unable to sustain the schedule beyond the first two or three months. Most of the coordinating was left to executive assistants. Cancellations were common. Faculty participation and residents' satisfaction levels were poor.

The following year, a faculty member was assigned the task of remedying that situation and was given the academic title of "conference director," with salary support. The conference director held focus groups with residents and faculty to try to elucidate the challenges and solicit ideas for solutions. Working closely with the staff of the office of surgical education, he oversaw the weekly dissemination of E-mail announcements about the details of the sessions for the up-coming week (i.e., topics, reading assignments) to all faculty and residents. He personally sent E-mail reminders to the faculty presenting the next week to confirm their participation. To gauge the magnitude of the task, the conference director in our department has kept a prospective tally of the time involved in coordinating these efforts. Over the last 12 months, he has spent about 70 hours, or roughly six hours per month, exclusively to sustain the conference schedule and maintain enthusiasm among the faculty and residents alike.

Resident attendance
Resident participation and attendance at didactic sessions remain a frustrating challenge since these sessions are completely educational and do not carry any "service" component. Even with the above described manipulations to the clinical schedule (see The 80-hour workweek limit), attendance was unsatisfactory. During the focus groups held with the conference director few issues emerged that made a difference:

The residents wanted to be involved in the designing of the curriculum. The conference director worked closely with a PGY-4 and a PGY-5 to remedy that matter.
The residents wanted to avoid having punishing measures taken for absences (decreasing vacation time, taking OR privileges away), so a senior resident was assigned to monitor and enforce attendance by paging all residents who were absent.

Resident preparation
Even more frustrating than the resident attendance issue is the preparation level of the residents. Based on the premise that residents are adult self-learners, we cancelled the monthly quizzes that we administered to the residents to monitor preparation. The result was dismal. A large proportion of the residents were unprepared and did not read the assignments. When this issue was approached with the residents during a recent focus group, the overwhelming majority urged us to revert back to the testing system. So we have decided to administer a pretest quiz of five to eight questions prepared by the resident facilitating the conference prior to each core conference. To stimulate some friendly competition, we plan on publishing the results of the tests monthly, with each resident assigned a number to maintain confidentiality.

Faculty participation
Two years ago, faculty participation was erratic and suffered from competition with busy clinical schedules and other academic commitments (i.e., student lectures, committee meetings). Last year, we initiated the Educator of the Day (EOD) program. All didactic sessions on any one morning are synchronized across one specialty (general surgery, vascular, transplant/ hepatobiliary, cardiothoracic, breast) with one faculty member assigned to be with the residents for three hours (basic science/core, preoperative, and senior case conference). The schedule is made at the beginning of the year, so the EOD has enough advance notice to manipulate the clinical schedule so that he or she can be free. The sessions are distributed evenly across specialties throughout the year to make it balanced. The conference director personally sends an E-mail to the EOD a week prior to the date to confirm his or her participation. If a conflict emerges, another faculty member from the same division substitutes since the conferences are synchronized per specialty. Since we introduced the EOD concept this past year, we have had exactly only two last minute cancellations due to unavailability of the faculty member. The conference director keeps a tally of participation of the faculty, which is then submitted to the chairman for consideration in the academic incentive plan.

The EOD program was obviously a great success in our program, preferred by residents and faculty alike. It did though reveal two problems:

The sessions were confirmed a year in advance with the EOD's themselves and not with each one's secretary. We have therefore had a few instances where the faculty member forgot to communicate that commitment to their assistant and conflicts arose. This year we plan to confirm commitments with both faculty members and their assistants.
Since the introduction of the EOD concept, participation of other non-EOD faculty members in our very popular weekly preoperative conference has dwindled. We plan to remedy that by continually reminding the rest of the faculty of the need to participate even if they are not EOD that day. We also have decided to make the preoperative conference a bi-weekly conference rather than a weekly one and to emphasize preoperative preparation and evaluation during the individual service conferences. This latter adaptation would offer the obvious benefit of having more than one attending from the same service to present different approaches to preoperative preparation.

Didactic versus skills sessions
A robust skills curriculum is a must in any surgical residency and must be seamlessly integrated with the didactic curriculum. The latter task is a challenging one. Our efforts have been partially successful. For the last two years our conference schedule consisted of five didactic sessions as follows:

7:00 – 8:00: Service Report (Mortality and Morbidity conference)
8:00 – 9:00: Grand Rounds
9:00 – 10:00: Basic Science/Core conference
10:00 – 11:00: Preoperative conference
11:00 – 12:00: Senior Case conference (PGY3-5) and Junior skills/conference (PGY-1, 2)

The skills sessions (live animal vivarium, cadaver dissection, and skills laboratory) were either carved out of the above schedule or conducted outside of the protected educational morning. That arrangement resulted in suboptimal faculty and resident participation in these essential sessions. In addition, sitting through five successive didactic sessions has proven to be onerous even with breaks in between sessions.

Our plan this year is to make the educational morning more flexible to integrate the expanded skills curriculum. Some days the sessions would look like the above schedule. On other days, it would consist of skills sessions mixed with didactic sessions, or it would only be skills sessions. The only didactic session that is maintained every educational morning is the Mortality and Morbidity conference, which is required by the RRC.

Discussion
The challenges we have faced in reforming our educational conference schedule in the department of surgery at the Georgetown University Medical Center are probably common at many other institutions. Some solutions we came up with worked while others were suboptimal (see Table). The important things to keep in mind when designing a schedule for an educational curriculum are flexibility and ways to adapt it during the year if problems arise. Another pre-requisite for success is the unwavering commitment of the chairperson of the department to provide protected time for the conferences and salary support for a faculty member to direct the effort.

CHALLENGE	PROPOSED SOLUTION
Work-hour restriction	Consolidate conferences
Consistency and sustainability	Conference director
Resident attendance	Buy-in from residents
Resident preparation	Quizzes
Faculty participation	Educator Of the Day (EOD)
Didactic versus skills sessions	Integrate the two

Online October 26, 2005