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When should you take the cake out of the oven? The correct, if somewhat glib, answer is, “When it is done.” In everyday practice, however, pastry chefs do not test the cooking batter every minute. Rather, the benefit of experience is translated into simple rules, such as, “Bake at 375° for 45 minutes.”  When should residents be allowed to graduate? The correct answer is a variation: “When they are done,” meaning when they are ready for independent practice. And here, too, we do not test for completion continuously, but rather follow the cake-baking rule: apply a certain intensity and duration of training, and confirm “doneness” at the end.  Even amateur bakers realize that when using an oven that does not get hot enough, the cake must stay in the heat a little bit longer. Yet similar logic has not been applied to residency training; specifically, there has been an 80-hour limit on the resident workweek, but the duration of residency training has not increased.  It seems to me that if we cut back the number of hours residents can work each week, and we do not increase the total number of weeks worked, we risk truncating the educational experience. This truncation is probably not a 50% reduction (for only in the ”Days of the Giants” did residents routinely work 160 hours per week), but 10% is not an unreasonable estimate. Add to that the inefficiencies of more frequent patient hand-offs, and I would bet that residents’ traditional clinical experiences have been effectively abbreviated by 6 months or more. We can teach a lot of orthopaedics in 6 months.  The question of why the work restriction rules were not immediately coupled with an extension of the duration of residency has a few possible answers. Cynics would say that this was just one of the many ramifications of the work-restriction rules that were not well thought out. A more neutral position holds that longer residencies would be better in the abstract, but there is no money to fund them. Or perhaps residency programs were unnecessarily long to begin with, and this shortening simply cut them down to proper size—recall that orthopaedic residency was, for most of its history, only 3 years long, following 2 years of general surgery.  Whatever the explanation, we still are left with a key question: What should we do now to best adapt to a de facto, abbreviated course of training?  One simple step would be to insist that future orthopaedic residents learn as much as they can before they even begin residency, and they demonstrate proficiency as a requirement for admission. Specifically, any aspect of orthopaedic surgery education that can be taught in medical school should be taught there; by doing so, we free up more time for things that can only be taught in residency. For example, why not insist that all students interested in our field take an advanced anatomy examination? At the same time, why not insist that all applicants complete subinternships in surgical intensive care, emergency medicine, and musculoskeletal radiology? It is not like the senior year of medical school is overly-rigorous as it is. Orthopaedics remains a very popular career choice among students, and we can increase the entrance requirements without creating a shortage of qualified applicants.  Beyond that, we must selectively lengthen residency for those residents who need it. In turn, we need to enhance the power of program directors to identify and hold back from graduation those residents who, while not failing per se, are simply not ready to graduate. Further, this power must be paired with a program that supports those residents who are not ready to be released.  Currently, hospitals are reimbursed by the federal government for residents’ salaries but only for the first 5 years of training. When a program currently decides that it must retain a resident for more training, it must pay for this extra year— a substantial cost. This strong incentive for programs to graduate “marginal” residents must be removed.  Training residents is not exactly like baking a cake, though they do have some elements in common, apart from cracking, whipping, and beating. To graduate the best possible residents, or bake the best possible cake, one must start with the best possible ingredients and allow the expert “chefs” enough discretion to get the job done correctly.

Orthopaedic Residency: How Do You Know When the “Cake is Done?”