Future Orthopedic Training, A Global Report

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Increasing quality of life by reducing pain and restriction of movement is the purpose of treating the orthopedic patient. Global obstacles in the path of that goal may vary but collaboration is required in order to maintain the high standard of orthopedic care that patients deserve. This was discussed and presented by a task group at the Beijing Summit of the 2012 Chinese Orthopaedic Association Congress and World Orthopaedic Alliance (COA 2013 Web). Medical knowledge, professionalism and non-technical as well as technical skills must be taught in orthopedic training. Technical skills include both visuospatial and psychomotor abilities as well as a strong working memory. Advanced visualization and simulation tools with metrics on performance are new educational methods which will improve these abilities.

Global challenges and systems under pressure

The scene varies from relatively easy access orthopedic surgeons to dire shortages. In India for example, there are less than 30,000 orthopedic surgeons catering to a population of 1.2 billion – 1 orthopedic surgeon per 400,000 population. There is an acute need to increase the number of trained orthopedic surgeons and also to continously upgrade skills.

Further education and training, depending on its source, may become problematic because of one’s own financial interests, links to industry, or conflicts with health insurances. Educational conflicts with one’s own practice may also exist due to different owners with varying financial models, and deficits in education and skills training.

Generation Y

Training the future orthopedic surgeon means training people born in generation Y i.e. between 1982-2005. Generation Y is technology savvy and multitasking. Having grown up in the information age, they require new teaching strategies since they are used to large amounts of easily searchable and available information. Generation Y prefers flexibility and autonomy which might create tensions to senior staff educated and trained in a different era. A lecture given does no longer mean a lecture learned. The vast and diverse amount of information available can result in information overflow. A balance between providing a large amount of information and filtering resources will thus be essential.

Working hour directives

To improve patient safety and doctors quality of life, working hour regulations have been implemented during the last decade in multiple parts of the world. Patients should not be treated by exhausted doctors just as airline passengers don’t fly with exhausted crews (Helmreich and Meritt 2001). Doctors’ time spent in hospital has thus decreased and unintended consequences include lack of continuity of care and, for the practitioner-in-training, a lack of exposure to rare pathology. There are conflicting results regarding the effect of working hour regulation on patient safety; both increased and decreased mortality have resulted.

“The elephant in the room”

The role of industry concerning education and skill training is debatable. Industry has a very limited role in education of basic trainees. However, training which involves new products and devices cannot be satisfactorily achieved without the inputs from and cooperation with industry. Undue influence from the industry may pose ethical risks. Globally, the public is increasingly aware of the connection between the industry and surgeons. The risk of creating mistrust between the patient and the surgeon must be avoided; transparency is crucial.

The aggressive nature of industry driven by a the obligation to return value to shareholders is risky if academic medical centers abdicate their responsibility for continuing education of medical practitioners. An imbalanced system must be avoided and we should be aware of unintended consequences of well-intentioned reforms. The “elephant in the room” is a metaphor for the effect of reimbursement where doctors and hospitals are rewarded for using expensive technology. This policy has resulted in a system that is biased toward transferring knowledge about new expensive technologies and against simpler and more cost effective procedures.

Skills academies

Continuous education, training and assessment is the key to achieve excellent long term clinical results. So far there has been much focus on technical skills training. However, there is an incresing awareness of non-technical skills such as situation awareness, decision making, communication skills, teamwork and leadership skills (crew resource management, CRM) (Flin et al. 2006, Meurling et al. 2013, Moorthy et al. 2006). It is prime time for a transition from the apprentice model to outcome-based education where knowledge, skills and attitudes are triangulated. The national or regional bodies have an important role in initiating and coordinating skills academies and also in defining minimal standards. This will enable comprehensive training engaging experienced faculty and state of the art education methods (Figure 1 a and b), hands on workshop, visualization, simulated surgery, procedures and systematic teamwork training. This need for state of the art training is paramount in all countries including the developing world.

The way forward

Process optimization should aim at standardizing protocols and checklists (Arriaga et al. 2013) and also educating patients. Evidence-based medicine should guide clinical practice and data collection. The Open Access movement means free and immediate electronic access to an increasing number of scientific journals which is especially important in the developing world with a shortage of libraries. Audits should be carried out periodically in order to optimize clinical outcomes. Apart from technical skills, communication skills, correct attitudes towards patients, and the ability to understand indications are paramount. Also, an ethical framework for conduct of surgery is mandatory.

International collaboration is the only way forward when improving the global standards of training in orthopedic surgery. Using a systematic approach will ensure the future will be bright for all.

L Felländer-Tsai
Department of Orthopaedic Surgery, Karolinska University Hospital, Sweden
President Swedish Orthopedic Association

K.M. Chan, Hong Kong
Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong
Past President, International Federation of Sports Medicine (FIMS)

K Holen, Norway
Department of Orthopaedic Surgery, University Hospital of Trondheim, Norway
President Nordic Orthopaedic Federation

W. Walter, Australia
T.P. Sculco, USA
S. Rajasekaran, India
M.H. Darwish, Oman
B.A. Kornah, Egypt
C.G. Rolf

Past president Swedish Society for Sports Medicine
Department of Orthopaedic Surgery, Karolinska University Hospital, Sweden

W. Puhl, Germany
H. Yuan, USA
H. Hedin, Sweden

Department of Orthopedic Surgery Falun/Ludvika, Sweden
Former secretary of the Orthopaedic Section of UEMS

References

1. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis
checklists. N Eng J Med 2013; 368 (3): 246-253.

2. Flin R, Yule S, McKenzie L, Paterson-Brown S, Maran N. Attitudes to teamwork and safety in the operating theatre. Surgeon 2006; 4 (3): 145-151.

3. Helmreich RL, Meritt AC. Culture at work in aviation and medicine: National,
organizational, and professional influences. Asgate Publishing Ltd, Aldershot,
England, 2001.

4. Meurling L, Hedman L, Sandahl C, Felländer-Tsai L, Wallin CJ. Systematic simulation-based team training in a Swedish intensive care unit: a diverse response among critical care professions. BMJ Qual Saf 2013. Epub ahead of print. PMID: 23412932

5. Moorthy K, Munz Y, Forrest D, et al. Surgical crisis management skills training and assessment: a simulation[corrected]-based approach to enhancing operating room performance. Ann Surg 2006; 244 (1):139-147.