E24 Richard Reznick On Competency – Based Medical Education

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Dr. Richard Reznick is a general surgeon and world-renowned surgical educator. He is currently the Health Sciences dean at Queen’s University in Kingston, Ontario. In this episode, recorded May 8, 2020, we discussed Dr. Reznick’s career, how he got his career in medical education started, and of course, all about competency-based medical education. Check out our show notes for links to Dr. Reznick’s papers.

Chad Ball  01:14

Well, thank you very much for being on our on our podcast, Cold Steel, Dr. Reznick. It’s an absolute pleasure, and we know as busy as you are, it’s a real honour to have you  on the show. Everyone’s very excited about you being here. For those folks who maybe don’t know you intimately or know you well, I think we all know you for sure. But we were curious, where did you grow up? And then what interested you in medicine? And then what was your training pathway? How did that look?

Richard Reznick  01:44

Sure. Well, it’s nice to chat with your Chad. And thank you for having me on your podcast, and congratulations on such a successful endeavor. Well, medicine for me started a long time ago, back in the 70s. So that’s before all your listeners were born, I think. I was a native Montrealer and grew up and went to McGill, for I was I think the very first year of CEGEP. So actually, they didn’t have CEGEPs in Montreal at the time — well they didn’t have enough of them — so McGill and other universities became the CEGEPs in the initial phase of that alteration in postsecondary education. So, I actually went to McGill, and spent two years and in what they called the sort of pre-collegial studies, and then they had a special program at the time for an early entry program. It was sort of a pre-med, accelerated route, not dissimilar to the QuARMS program that we’ve developed here at Queen’s. And so, I applied almost on a whim, to be honest, because I was an anthropology major at the time. Not sure why, but I was. And anyhow, one thing led to another, and I got in of course, once you make your mother happy, you can’t change tactics. And so, I went into med school at McGill, they did the program was a year preparatory and then four years medicine. So I did seven years at McGill getting my medical degree, firmly convinced I was going to be a psychiatrist for at least the first three years of medical school until fate would have it as you would understand when I did an appendectomy as a fourth year medical student at the Royal Vic at three o’clock in the morning and decided that that was a lot of fun and, and instant gratification and change directions towards surgery.

Chad Ball  04:02

How did the Toronto part of your career come to be?

Richard Reznick  04:06

So, after McGill, I signed my match form November 1976 and put Toronto hospitals as my first, second and third choice. And part of it was you know, being young having lived my whole life in Montreal, I wanted to get out and you know, see another environment but also part of it was the politics in Quebec, which at the time were quite difficult. In November 1976 the Parti Québécois came into power and I was quite concerned that this might not be the best place for me to start my career and so that was another motivation to go to Toronto.  I applied for … I wasn’t quite sure … 100% sure I wanted to do surgery. I wanted to do an internship. At the time, you could sort of stylize. There was something called a mixed internship with, you know, half one specialty, half another. And that’s what I wanted to do — half medicine, half surgery — and kind of see where I wanted to go from there. And Bob Stone, who was the very young Chief of Surgery at Mount Sinai Hospital at the time, said, you can do whatever you want as long as you come here. And so he signed me up. I actually became a straight — what was called a straight surgical intern — and I actually did six months medicine, six months surgery, because that’s what we bargained for, and then decided to apply to the surgical program in Toronto.

Ameer Farooq  05:39

One of the amazing achievements that you’ve had is actually becoming the Dean of the Faculty of Medicine, at Queen’s and very few surgeons actually get to that position. There are a few notable exceptions like Walter C. McKenzie in the West. What was that, what has that experience been like being the dean at Queen’s? And what made you interested in that position?

Richard Reznick  06:03

Yeah. Well, so you’re quite right. It’s been, as I now I’m on my last — my wife tells me 57 days —  it’s an appropriate time to reflect. It’s been an incredible experience to lead the faculty. In our case, that includes a School of Nursing, School of Rehab and the School of Medicine. And it’s been a terrific experience. But I guess winding back the clock, the motivation to it, as you might know, I decided long ago, back in the early 80s, to take a bit of a gamble on my academic route, and focus on education as a, an academic area of scholarship. And that led to many things. But including a, an educational, being involved in Educational Research Centre, and then a chair of a department. And I guess, I guess after five or six years as chair of surgery in Toronto, I had, well, actually, even before I had been approached about being a dean of another medical school, and that got me thinking about that pathway. And those opportunities, I guess, came up a couple of times over the course of my job as chair of surgery in Toronto, and I thought it’d be terrific to, you know, the job as chair of surgery was amazing, but to just then take another step and expand my scope of activities. And I guess the one thing that’s typified the dean’s job is no two days are alike. And the variety of problems and issues that you deal with are quite expansive. And so it’s been terrific. And I guess I’ve been gearing up to do something like that with my focus on education for so long, that it became sort of a natural evolution for me.

Chad Ball  08:08

It’s interesting, Dr. Reznick, being in Alberta right now with our government change and the cuts that have come and, you know, I certainly talked to and see Dr. Meddings, our dean here at the University of Calgary, and some of the, you know, I’m sure we perceive about 2% of the challenges that he’s experiencing on a daily basis right now, but, you know, certainly recognizing things can be hard. But what are some of the absolute best parts of your dean shift job?

Richard Reznick  08:35

Yeah, so so you’re quite right. Things are things are tough and there’s lots of challenges. But you’re but you’re equally right, that there’s a lot of benefits. So by far and away, it’s an easy question to answer, but far and away, the most exciting thing about being a dean is being engaged with our student body. Certainly, I when I give talks at Queen’s or elsewhere, I’m talking about all of our, the great things that I think we have and do. Our biggest asset by far and away is our students and being reengaged with medical students because, like most surgeons, although I taught some medical students, my primary focus was on resident education. Being more involved with the students in different ways, though, has been a real treasure. The luxury that we have in the medical profession to really get the best and the brightest applying to medicine is quite exceptional. At Queen’s we have for whatever reason, it’s become a very, very popular school and we choose our 100 students from over 5000 applicants. So and each and every one of them is interesting, creative, talented. One of the things that has been a treasure for us is my wife and I have had the students over for dinner, all 1000 of them over 10 years in smallish groups of 15 or so, and so we get the chance to chat with them a bit and at least break bread and also break open the line as well. And it’s been, it’s been such a, you know, such a treat and there’s such great students and are going to make such great doctors. So I’d say that’s been the single biggest pleasure of the job, although there many others.

Chad Ball  10:35

I can only imagine what that experience is like for the medical students. I’ve never heard… I didn’t know you’re doing that and I’ve never heard of, of any dean doing that. That must be remarkable from their point of view.

Richard Reznick  10:45

But you know, there is a bit of a tradition at Queen’s, although we didn’t know that when we… So when I got the job as dean, I was in my eighth year as chair of surgery in Toronto, my wife innocently said to me, Well, how are you going to stay connected to the students? And I said, well, you know, maybe I’ll do a little bit of teaching, which I actually ended up doing just a little bit, some surgical skills in the skills lab. And but she said, I so I told her that she’s, well, that’s not quite good enough. She says, why don’t we have them for dinner? And I said, well, what do you mean for dinner, I said, there’s 100 of them. She says, no, no, let’s have them for dinner. And so, it was my wife Cheryl’s idea. And she became very involved with you know… she would cook. It was a three-day affair: a day of shopping, a day of cooking and… a day of shopping, a day of cooking and then a day of cleaning up. And if it was if the dinner was on a Monday or Tuesday, I was a sous-chef on the weekend. But Cheryl took it very seriously and it really became a joy for us and meaningful. The last the last dinner we had was just before COVID hit and you know we had some champagne and we were all in a bit of tears and it was very emotional.

Chad Ball  12:11

Wow. It’s interesting, you know I didn’t know your  wife’s name was Cheryl because when you said that and you just described you know your experience over those 10 years with your medical students, that made me immediately think of Keith Lillemoe’s wife, whose name is also Cheryl, and it was interesting to watch, nevermind at the fellowship level, but at the general surgery resident level, she was an absolute dynamic and very important partner of his and I’m sure continues to be in Boston, in terms of exactly that. What has your Cheryl meant to your career and, and how your life?

Richard Reznick  12:45

Yeah, well, that’s a, you know, that’s a long… I could spend a lot of time talking about that… but in short, just, I think, as you’ve described. Cheryl and I met over, we like to tell the students because they asked each time at dinner, because they know the story, but they want to hear from us, over a bleeding chest tube when I was the senior resident in cardiac. And she was a cardiac ICU nurse. And she, you know, we’ve been married now for, I guess, 30 it’ll be coming up to 36 years. And Cheryl, after a fairly short nursing career, was a stay-at-home mom and for the last many, many years has taken that part that job the first extraordinarily seriously, as well as the job of working, you know, assisting me and being a partner with me in some of my adventures, including the dean’s job. So, Cheryl enjoys many of the social aspects of that are obligated for a dean and she’s taken those very seriously and helped me through all of those. So, it’s been terrific. And we’ve enjoyed, we’ve enjoyed working together on many things for many years.

Chad Ball  14:14

That’s amazing. That’s always so impressive from the outside to seek dynamic couples like that, that can work together so well in addition to being together. You’ve touched on it a little bit, and I think we’ve kind of mentioned it a little bit, but you’re really synonymous, your name and you, with medical education in Canada, and particularly surgical education. Just before we got on the line formally, I was just telling you, you know, a story about a very prominent American surgeon who would refer to you as “The Richard Reznick,” as in you know who The Richard Reznick is, and I always thought that was really high, high, high and subtle praise. Just curious, how did you get into the medical education business, so to speak? [2 second of inaudible]

Richard Reznick  15:01

So, you know, you would hope that it was well-thought-out, and, and well-designed and but, you know, like most things in life, it’s really a bit of circumstance and, in some ways, luck and being in the right place at the right time. But the story was that I finished my general surgical training, and I actually went, as soon as I finished general surgical training, I wasn’t 100% sure, what was next. And a friend of mine, who I had — he was a fellow and I was a resident — had become a staff surgeon at a community hospital in Toronto. And they had, one surgeon had died and another surgeon was sick, and they were down, and he was desperate for help and asked if I could come for six months as a placeholder, which I agreed to do, and loved it. It was fabulous. I mean, just the thrill of actually doing stuff, all the stuff you were taught and, and I was, I thought I would stay there for six months, and six months ended up being a little over two years. But right, early on, I decided I wanted to do academic be an academic surgeon and was trying to design a pathway to achieve that goal. So I thought, I had done a six-month research rotation during my training, which at the time was not insignificant, and I had a great time in that research training. But I decided that the traditional research pathway of laboratory research was going to require many years of dedicated work in the lab, likely at a cellular level. And even though that was of interest to me, I didn’t think I would be able to sustain an interest in fundamental biological research for the rest of my career. And so in thinking about other pathways, I thought about the idea of becoming a specialist in education, not really knowing what that meant, and went and tested the waters with maybe about half a dozen Toronto surgeons who I you know, who were my teachers and mentors, a couple of whom had focused in their later careers on surgical education. John Provan, for the name of being one name, and Jane Cohen another, and a few others, Bernie Langer, and to a person, they said, they thought it was a terrific idea. They also didn’t know exactly what I meant, or what it meant, but I got a lot of encouragement. And so through, actually John Provan, he sent me to meet a gentleman named Roland Folse, who was the chair of surgery at a fairly new medical school called Southern Illinois University in Springfield, Illinois, and suggesting that that school, had started had decided to make medical education/surgical education, its principal academic focus. So I went down there, and liked what I saw. It was a very exciting environment for medical education, which I can tell you a little bit more about after, some of medical education’s heroes actually started their careers there. And they offered me a fellowship, and said they would help me apply for what at the time was a $25,000 scholarship from the National Fund for Medical Education in the States. And so this was just about the time that we were getting married. And in addition too I kind of popped another question to my wife, in a breakfast room, in Kyoto saying, telling her I applied — by this time, I was doing very well as a young surgeon in Toronto at this community centre, and said, you know, I’m thinking about this, and if I get the scholarship, I think I’d like to go and her answer to me was, if that’s what you want to do, we’re moving to Springfield. And so that was the start. Maybe I’ll stop there, because it’s a, I could spend the entire hour telling you about, about that saga, but it was, in short I got a million dollars worth of education in a year’s time, and it was a fabulous experience.

Ameer Farooq  19:38

It’s pretty remarkable that you would pursue that and that you got so much encouragement, because I think, you know, now surgical education is a well-respected academic pursuit, but I don’t think it was always like that. And so it’s pretty remarkable that you and many other surgeons in Toronto recognized that as being an important thing to kind of target.

Richard Reznick  20:02

Yeah, you know, I mean, it’s always been, it certainly was at the time the orphan child of our academic tripartite. And, but I think intrinsically, everybody knew and understood the importance of it. But of course, where we hadn’t focused, and what’s changed dramatically in the last 30 years is the notion that the science of education and or the scholarship of education is a very bonafide academic pathway. So yeah, I took a bit of a gamble. But as I said, I was encouraged a lot by people who I cared for and thought very well of. And, but when, I didn’t know what I was going to do for that year, like when I, when I signed up, I wasn’t sure whether I was going to join some kindergarten teachers in “education school” or what it was going to look like. It ended up being a very stylized program for a guinea pig, and I was their first master student in medical education. And I was able to sort of stylize my own program. And it was a it was an incredible experience.

Ameer Farooq  21:12

You’re known for so many things. And I think particularly across Canada, you’re very, very well known for your work that you’ve done with around competency-based medical education. But I think that only represents one of many of your achievements. One of one of the other achievements I wanted to highlight was introducing the OSCE into the LMCC exams. How did that come about, and how did you come up with that idea?

Richard Reznick  21:38

Well, it’s a good time to discuss it. Because there’s actually a petition right now — I think I saw it being signed by over 1500 students — asking the MCC to do away with the OSCE,  or the part two, particularly in this year of turbulence around COVID. So the exam is, was at the time controversial and continues to be controversial. Well, it was a very interesting story. I’d come back to Toronto as a newly minted, quote unquote, surgical educator, and actually had had some OSCE experiences. When I was in Springfield, Illinois, they had done some of the very first OSCEs in North America, in Springfield. So I had had a little bit of experience and one of my collaborators at the time, and when I came back to Toronto, a gentleman named Robert Cohen, who’s now in Israel, also had had some experience and we teamed up a bit to think about running some local OSCEs in surgery, which we had started. And I then got a visit from a gentleman named Michel Bérard, who was the Registrar of the Medical Council of Canada. And Michel was in Ottawa, he, he flew down to Toronto, and he said he wanted he asked if I would chair a committee to investigate the feasibility and implemental, implementation of a national OSCE for licensure. So there I was a young surgeon, I think I must have been just two or three years into the my academic practice, given this opportunity to lead a national committee to do this. And that led to literally a decade of relationship with the Medical Council of Canada. So it was great it was, I was very lucky to get that opportunity. And it was just by, by circumstance that I’d had a little bit of experience and not many people had with the OSCEs. Michel is by profession and obstetrician/gynecologist, and I remember him telling me he wanted a surgeon to lead the initiative because he thought it would take a surgical personality and mentality to drive through some of the obstacles that we were going to face. which ended up being, I’d say true — not that a physician an internist couldn’t break through obstacles either — but he was convinced this had to be a surgeon, so that was the start of that story, and it was a great story and great relationship with the Medical Council.

Chad Ball  24:20

That’s really interesting. It’s always neat to hear the genesis of some of these things that those of us who come later through systems, you know, just sort of the way it is, and it’s particularly interesting to think that folks are trying to do away with it now.

Richard Reznick  24:36

Yeah, well nobody, so the impetus to start performance-based testing, generated from the fact that we were licensing people based on a paper and pencil test, and the regulatory authorities who were seeing — their complaints weren’t about knowledge, their complaints were about clinical skills, and professionalism and communication –and they said counsel, why aren’t you testing that?

Chad Ball  25:02

Right.

Richard Reznick  25:02

You know, why are you just testing that a doctor can fill out the right bubble on a piece of paper. And, you know, I remember when, in the early days of the, of the OSCE, we would quote Osler, who said something to the effect of, to sail the sea, the educational sea without books is to not sail at all and to, or to sail in uncharted sea. But, you know, to do medicine with our patients is to not fail at all. I’m not quite the quote, but something like that. And, so, the early days of the OSCE were very, very exciting. I mean, it was logistically challenging to at the time test, I think, was 1600 graduating students, across five time zones in two languages, with thousands of patients, standardized patients and thousands of examiners. So, it was the logistical challenge, not the conceptual challenge that, because conceptually, the OSCE was sound. Right, today, 30 years later, it may not be needed, and the students are right and may not have because we profoundly change the curriculum. There was no such thing as you know, teaching of professionalism, teaching communication skills, even clinical skills teaching back then was in its infancy. So the examination tail, wagged the curriculum dog, which was appropriate, and now 30 years later, all of our medical schools are filled with clinical skills teaching at a high level, as well as clinical skills assessment. So hence the challenge to the to whether we still need the part two.

Chad Ball  26:48

Competency By Design has gained so much momentum and it’s rolled out across the country, particularly in the surgical subspecialties that that you and I live in. And a lot of that, of course, was driven by your hard work. For our listeners, could you define CBD for us?

Richard Reznick  27:10

Sure, well, Competency By Design is the actual, almost not quite trademarked. But the Royal College’s, if you will, moniker of competency-based medical education. So I think it’s probably appropriate  to think about or define competency-based medical education. And for me, it takes on a very particular meaning, and the work that we’ve done in CBME, in my mind, takes on a very, very special meaning. And first and foremost, it’s to get away from the notion that if you spend a certain amount of time in a particular specialty or jurisdiction, that you’ll be able to then achieve all of the all of the elements that are appropriate to become a specialist, or whatever the particular curricular design is. So, it does away with the notion that time equals competence. It involves, often for the first time in decades in a particular specialty, having a really hard look at curricula, and really paying attention to what’s needed in the training of specialists, which change over time. The fact is, though, our curricula don’t change and they become ossified. So, to be a big part of CBME is having that hard look at the curricula. And then, in our case, through a system of milestones and EPAs, EPAs being Etrustable Professional Activities, making the criteria for advancing from one stage to another very explicit, important. An important element is that this implies that there needs to be much greater faculty-resident engagement at a very fundamental level, and dramatically ramped-up assessment. And then in our Canadian context, what CBME is also involved in making very explicit something that’s been implicit and sometimes hidden, and that’s that medical education has a cost and at their specific cost to, to delivering high-quality education and making those explicit. And I guess the last thing I would say, because I could again, go on for the whole hour about competency-based education is that it changes the dynamic more towards residents’ empowerment, and puts, and resident responsibility. And so a fundamental element of the program is to, if you will, to transfer power from the teacher to the learner.

Ameer Farooq  30:23

I think, in some ways CBME is very counterintuitive, especially for someone who has a background as a surgeon. I think, you know, traditionally, surgeons just start as residents, and then somehow magically, at the end of five years, they put in hours and hours and hours in there, and they’re surgeons, and, you know, it’s hard to actually envision someone challenging that notion, in many ways. I’m curious how you actually came up with this idea, or why you thought of this.

Richard Reznick  30:53

So, I absolutely didn’t think of it, think about it. So, competency-based education, as a, as a movement, if you will, started sometime in the 60s, with its roots deep in behaviour theory. And it’s been used extensively in K to 12, aviation, medicine, and many sorry, in aviation and, and many other areas of multiple fields of education. So, I like to think about CBME competency-based medical education as a 50-year-old movement that’s just taken medicine by storm. In medicine, it’s been talked about, and they’ve been sort of experimentation with CBME, for 15 to 20 years now. So, I actually started thinking about seriously focusing on CBME, when I became chair of surgery in Toronto in 2002. And I decided that one of my goals was going to be trying to do launch a major experiment, that would look at a different way of training. And of course, at the heart of it is the training that you described just before, what some might call the, you know, learning by osmosis. Because when you’re a surgical trainee for 100 hours a week, and you were exposed to so much surgery, learning by osmosis was not impossible, and it’s certainly a reasonably appropriate way of approaching surgical training. But as we all know, the changes of last 25 or 30 years have dramatically impacted the surgical work week, how we trained, how long we can our residents can be in the in the workplace, appropriately so, and dramatic decreasing independence in the surgical area. So, it seemed to me that we weren’t ever going back to a 100-hour work week. And what we had to do, and to me what’s implicit in CBME, is making the very most of each training hour and changing the framework from certifying at the end, by virtue of the fact that someone has spent five or six years at 100 hours a week, to making sure that each step along the way was affirmed as competence in more building-block fashion. So that was how my interest evolved, and I decided I wanted to see if we could launch a residency program that was rooted in competency-based education somewhere in surgery in Toronto, and we ended up doing it in the area of orthopedics, which has been a fabulous successful experiment.

Chad Ball  33:59

Dr. Reznick, I’m sure, you know, the rollout of CBME in Toronto, wasn’t all roses, particularly in orthopedics. I was curious why you chose orthopedics and how that came about, as well as what some of the hurdles or struggles were in that early time.

Richard Reznick  34:18

Well, so the reason I chose orthopedics was because at the time both the program director, a gentleman named Bill Kraemer, and the chair of orthopedics, Ben Alman, who’s now the chair at Duke, were wildly enthusiastic about the prospect. And at the time, I was chair of surgery which had 10 surgical divisions. And there wasn’t that dyad of dramatically, dramatic enthusiasts in any other specialty. So I decided to go with orthopaedics because of that fact that I had a chairman of the department who really wanted to do this, was willing. And Ben was a fundamental stem cell biologist. So it wasn’t his natural inclination, but he thought it was a great idea, and wanted his department, the division, to step forward. And Bill Kraemer was at Toronto East General, a very terrific program director — the program was in great shape, they had just gone through an accreditation with a five-star review. And so I thought it was a good place to start. We had a thought about plastic surgery, who were equally interested, but their chairman moved to California, so and we thought a few other programs, anyhow we settled on orthopedics. I don’t think it was, there were challenges, but it wasn’t a struggle, because the orthopedic community in Toronto, were terrific. I mean, they were just amazing. Especially for a division that had, whose claim to fame over many years had been rooted in, call it, technical excellence and technical innovation. They became enthusiast. Of course, you know, like any group of, I can’t remember how many orthopedic surgeons there were in Toronto, but at least 60 or 70, or maybe more, there were a few naysayers. But we went through a fairly rigorous change management process, which included a lot of communication, and allowing the naysayers to have their say, and getting them inside the tent rather than outside the tent, and working with them. And I would say that that change management process worked very well. Ben and Bill and then Peter Ferguson and Mark Newson and I and others became thought leaders in orthopedics and, and really, really made it fly.

Chad Ball  37:16

It’s amazing that you had such a keen partner out of the gate, and I’m sure that made all the difference as an example, really to the rest of the country. There’s no doubt. How do you respond to clinicians, one-off clinicians, maybe, or groups that would return to you — you sort of touched on a little bit with regard to the impact on the actual individual faculty or staff surgeon — there’s too many evaluations, you know, I’m not being paid for this, sort of that negative view of it. How do you frame that?

Richard Reznick  37:44

Yeah. Well, so at the end of the day, if we do, so at the end of the day, if we think we can deliver a higher quality of education, I don’t think there’s much pushback to, it’s worth it. That, and nobody can challenge the fact that the challenges of modern-day surgical teaching are very dramatic compared to what they were 30 years ago, for multiple reasons that we’ve sort of just briefly touched on. So I think fundamentally, there’s not much pushback to the notion where there is pushback is, just what you say, is where am I going to find the time, in some circumstances, in some groups, too the issue of compensation is important, and comes up. And to a certain extent, some people believe that the dramatically ramped-up assessment is more of a tick box exercise than a true assessment. And to be honest, there’s, you know, there’s some merit to it if it’s not taken seriously. But at Queen’s, you know, you may know, we’ve decided to roll this out to every single specialty and went on a bit of an experiment at Queen’s. And there’s no question we’ve done fairly systematic studies of, now, our faculties, belief systems in CBME, and we’ve seen dramatic changes from tremendous skepticism to reluctant acceptance to, I’d say, celebrating, that we’ve been able to achieve it and that it’s a better way of training.

Ameer Farooq  39:33

I think, fundamentally, Dr. Reznick, one of the paradigm shifts of CBD or CBME, is that, kind of what I was alluding to earlier, that it really forced people to think about surgical education differently. It changed people from thinking about surgery as, like, this learning by osmosis, to envisioning surgery as a series of goals or series of milestones. How do you think about surgery in that way? Like, is it really truly possible to break down everything that we need to learn in surgery, both from a technical but also a professional and cognitive domain into a series of goals and a series of achievements? How do you think about that?

Richard Reznick  40:25

Well, so I think, so I think you’re correct that, at its maximum, this, it can become, if you will, deconstruction as to the, to the observed. And it depends on how creatively you can define the building blocks. My sense is, the Royal College has done a really good job of this, by reconceptualizing the phases of becoming a medical specialist, or a surgeon on our case, from the early transition period, which is meant to just be a familiarization initiative over several months to core training, and then to transition to discipline, sorry, transition to discipline, then core training, and then transition to specialty. So I think that’s a good framework to think about it. And at each major milestone, there’s a competency committee that looks at now a portfolio of assessment, that really gives you a mosaic of an individual’s capabilities, and makes a much more, I’d say, reasoned judgment about the progress. But the other thing that I think that has been achieved with competency-based education is we can identify struggles and problems much early on and much earlier, which has always been a big problem in our current system that, often, we find out in later years of training, that there’s some fundamental problems, and they’re hard to address then. It also changes the concept of assessment from, you know, one or two major assessment hurdles, to continual assessment, which makes it more formative, which, of course, is what we should be doing. So, I don’t see it as breaking it down to the minutest parts as the fundamental element of it, I see it as a whole system of change.

Chad Ball  42:42

Dr. Reznick, you briefly mentioned, the disconnection of the traditional link between length of training and really production. I was curious when the rubber meets the road, and how you see or do you see any real changes in the total duration of training occurring through CBME?

Richard Reznick  43:06

Right, so the time-invariant aspect of CBD or CBME is one that people always focus on, but probably is the least important, in my view, of the whole, element of it. Because certainly, our experience, the Toronto experience, which is now almost a decade, has been that somewhere around half of the trainees have ended up finishing what used to be a five-year curriculum in four years, and being eligible to take their fellowships. So that’s the data. But, it wasn’t the focus. The focus wasn’t to race through, the way the Toronto program created its structure it was it enabled accelerated pathways, but it wasn’t the focus. And my sense is in most Royal College specialties, it will all continue to be some form of hybrid where it allows for the exceptional situation of someone to advance more quickly, or take more time if they need, and allow for that flexibility. But you try to predict what it normally would take to go through a, perhaps either a rotation or series of experience to meet the competency framework, and you predict, and then you’re likely going to get there. One of the general criticisms that I hear all the time is, you know, well what about the service requirements and how, you know, how can you, what are we going to do if someone needs six years or if someone needs, you know, for years. The reality is in medical school, you know, we have, in our case 550 residents, we get bulk transfer, we get transferred funding, and we have residents coming in and out of the program all the time. There’s paternity leave, maternity leave, illness. And so it’s very easy to be flexible with the timing. And, you know, it’s my fundamental view that a learner should take as much time as he or she needs to achieve the skill set. And then we should move them on to the next stage.

Ameer Farooq  45:26

It’s particularly interesting to talk about CBME in the time of COVID, where there’s been some major disruptions to resident training, where residents have either been redeployed, or, like, for example here in Calgary, our residents have been asked to stay home unless they’re on call, although that’s starting to perhaps lighten up here over the last week, how do you see something like CBME adapting to a pandemic like COVID, or potentially if we have more crises like this, more pandemics or crises in the future?

Richard Reznick  46:01

Right. Well, I think we’re all trying to understand how to deal with the pandemic situation. I guess, the first thing I would express is a very fundamental, philosophical view, that there’s only one place our residents should be during this crisis, and that’s in the hospital. I’m saddened to hear that Calgary’s made a decision to suggest that that’s not their place. Maybe I’m misinterpreting what you just said. But, and so too, with our medical students. I tried to keep our medical students in the workplace as long as I could, obviously, with safety front of mind, for them and the patients and everyone. But this is a once-in-a-generation learning experience for all of us, including our learners. My own view is, as soon as you take an oath to become, enter medical school, you understand that you are, there are some, you know, our profession, like many professions, have some inherent risks. And so I think the place for all of our learners right now is in the hospital. And it’s up to us to be smart about it, and structure it, you know, in a safe way. So, of course, you wouldn’t send a novice medical student to, to work on a COVID ward. But there’s all kinds of ways our students can make contributions, and our residents, to the system. And everybody should be actively engaged in, in helping out here.

Chad Ball  47:44

Dr. Reznick, you recently published a paper in the Journal of Surgery that outlines you know, many of the principles and, and the process in terms of delivering CBD across the country. And I would encourage anybody who’s listening to look that up, because it’s a great document. I think we’d just love to close with you, you know, first of all, thanking you again, for your incredibly valuable time, but also asking a more broad question, which is, for the surgical trainee, i.e., resident who’s interested in a career in surgical education, how would you best advise them to do that? Part one, to pursue that? And part two is, do you have any closing comments or thoughts at a 30,000-foot-level for residents in terms of their necessary skill acquisition in the context of CBD?

Richard Reznick  48:40

Well I’ll take the first question first. And I, I’ve had the privilege of spending hundreds of hours with probably hundreds of residents and fellows over the years who are thinking about surgical education as a career pathway. And obviously, for me, you know, I’m an unabashed enthusiast, and apologist for the fact that one of the fundamental things we do in our academic world is the responsibility of teaching and training the next generation, and we should be doing it, we should be doing it in as scholarly a way as we can. And there are, there are a multitude of things that we can do better. So, I think it’s a terrific pathway for those who are interested, like most pathways, getting some formal training in the area, to me as a sine qua non. There are many, many programs now leading to expertise in medical or surgical education and there and then virtually every school also has the Faculty of Education. So, there’s lots of ways of accomplishing the skill set. And, and it’s a wonderful way of blending a clinical career and an academic career through that focus. So, I did it at a time when not many others had contemplated that route. But it’s so heartening to see so many of our young trainees now embracing medical education as a career pathway. Your last question about CBD at 30,000 feet, if I’m understanding it correctly?

Chad Ball  50:40

Yeah, you bet.

Richard Reznick  50:41

Yeah. Well, I think training with training is evolving. And, you know, when I think back, you know, my thesis project in 1985, was a, no this would have been 19, sorry, 1984, was a randomized trial of sleep deprivation and surgical performance. That was this was actually before the Libby Zion case, which was in ’84. So, I didn’t know we were about to enter into a dramatic change in work hours. But what we’ve seen in the last 30 years is a fundamental change to the way we teach surgery. And so, with that fundamental change, what we’ve tried to do in the last 20 years to react is skirt around the edges, as opposed to really cut to the centre of what the problem is. And to me, at the very core, is making the making the most of every last training moment and making sure that we make every single moment the very best we can, and making sure that our trainees are accomplishing the goals that we set out for them, which involves much more comprehensive assessment. So, I’m confident that the next generations of surgeons are like, we have only one dream, right? You do, Chad, I do. And that’s that the next generation of surgeons can’t be just as good as you are. They can’t. They’re just as good as you are, we will have failed. They need to be better.

Chad Ball  52:27

Yeah. There’s no doubt. There’s no doubt.

Richard Reznick  52:30

And so that’s our dream. And that’s why I’ve dedicated the last 30 years to that dream.

Ameer Farooq  52:44

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback,  so feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.