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Markku Nousiainen’s Update on the Competency Based Curriculums

Markku Nousiainen
Markku Nousiainen

“Changing a system of education is difficult, sometimes frustrating, but persistence pays off”, says Markku Nousiainen, Orthopaedic Surgery’s Program Director. “Our Division knew that switching to the Competency-Based Curriculum (CBC) was a good idea, and our experience since 2009 has shown it to be true. One of the big reasons why it has been successful has been the support of our faculty and residents. The successful outcomes of our program played an important role in the Royal College’s decision to implement Competency-Based Medical Education (CBME) in all postgraduate training programs, through the “Competence by Design” (CBD) initiative which is running between 2015 and 2022. Several surgical specialties in the United States are implementing CBD and it is gaining traction in the United Kingdom and Australia. Our experience, including our mistakes and solutions, has been very helpful to those that are implementing similar programs locally and elsewhere. Richard Reznick (whose idea it was to try a pilot training program that was competency-based over a decade ago), Bill Kraemer, Peter Ferguson and I get lots of calls for advice and we have given many courses in how to design and implement CBME curricula.”

As Markku learned it, the story of the CBC begins with a call one day to David Backstein from Richard Reznick, who said: ‘Let’s give competency-based training a shot.’ Despite the doubts entertained by other Divisions, the Orthopaedic Surgery Division (led by Ben Alman and Bill Kraemer at the time) decided to implement a pilot training program based on CBME principles in 2009. With the extensive work in curriculum redesign by Bill Kraemer and Peter Ferguson, the training in the Division was significantly modified: off-service rotations that usually focused on managing non-clinical “scut work” were eliminated, as the experience on those rotations did not typically lead to successful learning outcomes. The Division applied for approval of the novel training program through the Royal College and got the ok. The new curriculum allowed for more efficient and effective learning. Instead of having orthopaedic residents rotate as the lowest ranking member on an internal medicine service taking care of less exciting, often resolved inpatient cases, residents were moved to the medicine consult service, where the experience was more demanding and relevant to their career in surgery.

The most important aspect of the CBC program is the assessments and feedback the trainees receive. Residents are evaluated intensively at least 3 to 5 times as much as they were before its inception. Evaluation tools, known as Entrustable Professional Activities (EPAs), have been developed to assess trainee competence in the clinic, ward, operating room, and ER. Faculty sign off on the level of competence a trainee exhibits in key activities related to the specialty, such as managing a patient requiring surgery for a hip fracture or total knee arthroplasty. In addition to the assessments, residents obtain summative and formative feedback on their progress, allowing them to understand where they are on their learning curve.

The pilot version of the CBC ran into one big challenge. Initially, trainees would stay on rotations until they achieved competence in the skills targeted for that service. This led to significant scheduling problems, as some trainees would need either more or less time on a rotation until they were found to be competent. In fact, two-thirds of the residents in the pilot finished in 4 years instead of the usual five. The program went back to a time -based curriculum in 2013 in order to solve the scheduling problem. Currently, the vast majority of trainees complete the core training rotations in four years; the fifth year has become an opportunity for enhanced elective or research opportunities to allow the residents to ‘transition to practice/fellowship’ and to complete their Royal College exams (This solves the Sandra de Montbrun’s question: ‘Why are surgeons operating in practice before they are certified?’ (see Surgical Spotlight article)”.

Markku and his wife Brigid, who is a veterinary technician from Vermont, are raising three children: 11-year old Nora is teaching her parents how to use her insulin pump, 9-year old Ester and 6-year old Johannes are active in sports, dance and music. The family spends time together at the cottage or by travelling to at least one interesting place each year (usually coinciding with a meeting).

Markku describes his job as “living the dream of doing formal research in education while practicing surgery. I devote one half day per week to research and administrative tasks, but in fact the only way to do the job appropriately is by working around the hours dedicated to clinical responsibilities.

After his Bachelor of Arts Honours Degree from Queen’s University, Markku completed a Master of Science in Biology, studying osteomyelitis at the University of North Carolina at Charlotte. He then completed his medical degree at the University of Toronto and a Master of Education from the Ontario Institute for Studies in Education, specializing in Health Professions Education. He completed residency training in Orthopaedic Surgery at the University of Toronto, followed by two fellowships, one in adult lower extremity reconstruction with Allan Gross and David Backstein at the Mount Sinai Hospital, and another in orthopaedic trauma with Dr. David Helfet at the Hospital for Special Surgery in New York City. While in New York, Markku looked into the role of computer navigation and its role in teaching surgeons. The technique replaces fluoroscopy, reducing radiation exposure by using infrared or electromagnetic guidance. Although navigation is very useful for precisely and accurately placing orthopaedic implants, it is not used by most surgeons due to the set-up time (which takes about 20 minutes for each case). Markku relates that “if 20 extra minutes for each case at Sunnybrook would mean the number of cases completed each day would be drastically reduced – a problem for patient throughput in an age of restricted resources”.

Markku works at both of the campuses of Sunnybrook. He does total hip and knee arthroplasty at the Holland Orthopaedic and Arthritic Institute. He describes it as “a great place to be - extremely well-run; a focused factory of anesthesia, nursing, physiotherapy and surgery”. He also does trauma surgery at the Bayview campus. He says that the trauma program is also great – “an excellent collaborative effort of the surgeons, nurses, anesthetists, ER docs, and allied health professionals helping patients when it matters most”.


[See related article on Education Day]

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