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Sebastian Tomescu
Sebastian Tomescu

Sebastian Tomescu learned about the CBC (The Competency Based Curriculum) curriculum on the CARMS website and during his interview. When the program director Bill Kraemer asked for volunteers, half of the residents applied. Sebastian liked the module idea. He thought that it seemed more orderly than programs where residents rotate seemingly at random through psychiatry, then surgery etc. He preferred a more ordinal approach and likes setting the pace for his education. He was not looking for a shorter residency, but for the self- study aspect that he had experienced as an undergrad at MacMaster.


The basic skills module in the Mount Sinai skills laboratory was excellent. CBC residents learned to use power tools, working with bones and cadaver models. They learned how to gown, how to position patients on the table and other fundamentals Senior residents, fellows and cast technicians taught the basic skills. The senior residents who were involved in teaching said "I wish I had had this at the beginning".


For this module, Sebastian was registered at five or six hospitals. He was called to the trauma rooms for fractures, received instructions like "go to Mount Sinai hospital tomorrow, there are two hip replacements in the operating room". He did one month of medical consults in the middle of the rotation. This was the only off - service experience besides the ICU. Doing the actual medical consult was quite different from following a medical team around as his colleagues in the standard curriculum probably were doing. "The medical residents were impressed that the orthopaedic surgeons could do the consults. That used to be off limits to surgeons, but we had the time and energy and enthusiasm to do them well. We learned how our medical colleagues think and we learned the value of a preoperative medical consultation. This was a better off - service rotation than the vascular ward or the emergency room where some of this content material is ordinarily learned. We went to two or three hip operations per day, each of us got 20 or 30 hip operations in two or three hospitals. We covered call that day."

Q: Was the perception that you were "stealing cases from the other residents as a visitor" a problem?

A: "This was solved by always working with a senior resident and carrying the pager that day. We also did regular call. When we went to Mount Sinai or Toronto East General for a surgical case, but we were not asking where the operating room is, etc. That had been solved during orientation in module one. We had spent three days at each of the hospitals and knew our way around."

"We were tested midway and at the end of the module. The exams were oral and written. There were also procedural exams - we were given a hip case, and we had to know the imaging, how to bring them into the operating room, how to do the checklist, how to do the history and physical and how to dictate the note -it was not just a skin to skin operation. We were also required to know how to direct helpers and focus on evidence. We were very busy - we were forced to read and be able to do and explain hip fracture like in a thesis. This kind of examination gives you confidence. We have had more orthopaedic surgery - 10 months in one year - than the 6 months we would have in 2 years of standard curriculum. We have met more staff and been in more hospitals than the control group. We had the best teachers: Hans Kreder- where the strategy cards were really good; Oleg Safir, Peter Ferguson, and William Kraemer were very involved."

Q: Will this become the new method of training residents?

A: "Timing is tighter, safety is tighter these days, but I think it will. We'll pioneer it."


"We did '100 Steps to Arthroplasty' in the skills lab on cadavers. The staff pushed me to be able to do the whole case. It may help to put arthroplasty with the hip fracture module."

Q: Isn't there evidence that over time people forget skills they learned in concentrated periods of study?

A: "We will get recall stimulation when on call and also do the advanced versions, so we won't forget what we learned in this intensive training."

Sebastian came to Kitchener, Waterloo from Romania in '96, when he was in grade 7. His parents are family doctors. He did premed, then kinesiology at Waterloo. After 2 years of research, he was accepted at Queen's medical school. When he had to decide between neuroscience vs. surgery, "the surgical rotation did it". Sebastian feels students need more exposure to surgeons early in their education. He plans to study for an MSc in the Surgeon Scientist Program.

Jeremy LaRouche is currently in the paediatric trauma module of the Competency Based Curriculum, because in summer there are lots of fractures in children to be treated. There are 21 modules in the CBC. All of them are experience - based, except ICU and the medical consult rotation.

Jeremy LaRouche
Jeremy LaRouche

Jeremy has a very positive impression of the CBC so far. He was given the objectives of the program at day 1 and he has been assessed in each module by oral and written examination and assessment of his skills at performing a history - taking, physical examination and performing surgery. The CBC gives more education at the front end than the standard Halsted model of residency. In the early training period there is a focus on how to use the instruments and other fundamentals. These sessions are open to his classmates who are not in the CBC - "they come as often as possible". His Hospital for Sick Children orthopaedic rotation isn't a simple orthopaedic time-based rotation. His focus is on trauma; he does occasional clinics and helps in the operating room, but his main responsibility is to carry the trauma pager. He works in the Emergency room as a member of the trauma team.

"Regulars" that is those in the standard curriculum tend to fear CBC residents as potential "case thieves", but Jeremy was accused only one time in the entire year. The senior residents seem to enjoy teaching the CBC residents. It's easy to resolve this problem on scheduled or elective surgery, but harder to manage on the unscheduled cases. In the present module, he is not having much OR experience as most paediatric fractures are treated non-surgically. He attends the fracture clinic four days, carries the trauma pager three days, sees emergency cases and might sneak into the OR, particularly at night or on the weekend. In contrast, when he was on the arthroplasty service, he was in the operating room four days a week.

"This has been a great rotation, the pager is the important link. It pulls us to our module goal". To meet the experience-based goals of the program, CBC residents are often required to go to where the specified procedures (e.g. arthroplasty or fracture plating) are being performed. They are registered and familiar with all ten hospitals. He crosscovers in many of them where needed, "earning points for help rather than theft". He is not just filling the ranks of the time-based resident complement. Members of the "control group" don't do rotations at Sunnybrook, St. Michael's or Hospital for Sick Children in the first year, so he is not competing with them. He is treated at these hospitals like a member of the team after the first several months. He has been in as many as five hospitals in five days. Sometimes his pager goes off and he is asked to respond to extension 3631. The question is at which hospital?

Jeremy has worked with 90% of the senior residents and feels he will be better recognized next year, when he joins them on other services. There is necessarily a tension between case experience and "the help that is needed", i.e. time -based notion of a resident's role. Working out the best resolution to this is an important evolving issue. In answer to questions, Jeremy says "I feel that I am way ahead my PGY 1 contemporaries in experience and more satisfied and confident. In some ways, in 11 months of orthopaedic surgery, I feel like a PGY3 in the standard residency group. That's because they have 24 months of experience, but only 12 months of Orthopedic Surgery, the other time is on required non-orthopaedic electives." The two experiences are not the same, as the CBC resident has a less linear picture of the evolution of a surgical problem in an orthopaedic patient. If he were filling out a report card, it would say "this year has been excellent, resource-intensive and A+ for education. There is less ambiguity, and more focus, more independent responsibility, but it is less broad."

Jeremy likes being in an experimental group. He was in the charter class at the Northern Ontario School of Medicine where his experiences were analogous to his current educational modules. He is a fourth year navigation officer in the navy with a total of 10 years naval experience. He enjoys decision-making. His undergraduate degree at the University of Toronto was in Economics and Finance. This background helped him get into the CBC program. Some of his colleagues said "no, thanks" because they disliked the fact that there would be an exam every 6 weeks. He is now on the selection committee for the next class of CBC residents. They look for characteristics of an independent learner.

Q: What are the problems?

A: "More effort is required in the CBC program. On the other hand, it is nice that you could extend your rotation - for example to become a spine whiz. I want community orthopaedic surgery rather than an academic program. There is a research module, I suspect I will do clinical research within my own practice, mostly at nights and weekends."

Jeremy's parents are geologists. They moved with him to Ontario from Quebec at age 8. In his naval program he trains in navigation two nights per week from 6.30 to 11 PM. He likes serving his country and would like to serve in Afghanistan. He does martial arts, rock climbing and some guitar. He taught karate and emotional intelligence to school children. This has been very beneficial to the children in strengthening their responses, understanding their feelings and managing fear. Jeremy has recently become engaged. He gives great credit to Bill Kraemer and Peter Ferguson who "have anticipated all the problems and worked hard to make this program work for us".


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