Learning from a surgical discipline, with Dr. David Horne
Since July 2018, Dr. David Horne has been program director of the division of cardiac surgery at Dalhousie University. Before becoming program director, he was the program’s CBD lead for a year. In this discussion, we hear from Dr. Horne about his department’s journey toward CBD implementation, which goes live on July 1, 2019.
How do you see your program, faculty and residents benefitting from CBD?
The people who will benefit most from CBD implementation are the residents themselves. CBD provides residents with a clear roadmap on how to progress through training. It requires them, for example, to perform specific operations, where historically some programs might not have given their residents the level of exposure they needed to do all that work. Under CBD, every resident in the country is required to qualify to the same precise standard. That’s positive for residents and our program overall, and will challenge some programs to better prepare their residents.
Similarly, in the previous system, we saw some residents progress not as much as they could have, but the evaluation system didn’t reveal that to us with objective evidence. CBD gives us the structure and evidence we need to identify the struggling resident and either help them become a surgeon or help them realize this is not the right career path. If the process takes years longer than usual for a few residents, then that’s the reality. Everyone should emerge from our programs much better prepared for independent practice.
What are you most proud of in Dalhousie University’s journey toward CBD implementation?
I’m particularly proud of our residents, who have gone out of their way to help map a new clinical rotation curriculum to the requirements of CBD. I’m also proud of Dalhousie University for the support and hard work it has put in over several years to ease our transition to CBD. Dalhousie has run many workshops to help us prepare, and also provided us with some effective software for managing evaluations. The software component has been one of the keys to success.
What is the biggest lesson you have learned so far?
It’s critical to prepare at least two years in advance for the transition to CBD. This is especially important in a surgical discipline because so many elements must be managed in clinical cardiac surgery care, including getting staff buy-in. It’s a big ask to have busy surgeons manage evaluations at the end of their long day. We must all take the time and care to implement a CBD system that is simple and seamless.
Within a surgical discipline, what are some of the greatest challenges you have faced in implementing CBD? How have you overcome them?
One major challenge in applying CBD to a surgical discipline is that residents have many operative skill EPAs to meet, yet we only do one or two procedures a day. This means the process can take a great deal of time and effort compared to a medical practice where a resident may do many patient consults and interactions in a day.
Also, as I’ve said, surgeons generally work long days, and it’s a lot to have them do evaluations on top of it. One key to ensuring staff buy-in is to is to make CBD implementation as easy as possible for them. It’s especially important to develop or purchase a software system, as Dalhousie has done for us, that can be accessed on a mobile device. You lose the effectiveness of CBD if evaluations are not occurring real time “on the run.” For example, if I had to go back to my office computer to manage the residents’ evaluations, it probably wouldn’t get done nearly as effectively, as I might only get to that a day or two later.
Prepare. Give yourself two years of lead time and invest by attending workshops and understanding the principles and process involved in CBD implementation. Start early by incorporating new principles such a competence committee, and by exposing staff to CBD in several sessions. Ensure you have a well-organized program administrator in place at least one year prior to your transition to CBD and do not change administrators part-way through; the evaluation process is so much more intense than under the former system, and the program administrator is key to ensuring residents and staff understand which EPAs have been completed and which have not. Also, start working on your rotation curriculum a year before the transition, and do it by using people – namely, current residents – who know the rotations so they can help with curriculum mapping first, followed by service staff input thereafter.