Orthopaedic education in India, the UK, and Germany
This chapter hopes to explore how orthopaedic residencies are presently organized in each country, what recent changes have occurred, and what are the strengths and weaknesses of each country’s programs.
India is the second most populous country in the world, 1.25 billion in 2013, with a very diverse economy and somewhat differing medical burden than is seen in Western Europe and the United States. There are also less doctors in India, 0.7/1000 population versus the 2.45/1000 seen in the United States . Because of poverty, the burden from infectious disease remains relatively higher than in Western countries [5, 6]. Safe drinking water remains a problem for a large segment of the population. Tuberculosis remains prevalent in India [5, 6]. That said, there have been tremendous strides over the last 50 years to decrease this disease burden. Because of improvements in public health, there has been an increasing proportion of the population deaths attributed to trauma rather than infectious disease . The practice of orthopaedic surgery has also changed. Orthopaedic surgery practice still continues to be largely for the treatment of trauma and infections, but steadier progress has been made for a segment of the population to have care available for elective spine, adult reconstruction, and sports diagnoses [1, 5]. Therefore, the practice of orthopaedic surgery is slowly infusing more sophisticated (and expensive) care commonly seen in Europe and the United States.
Unlike the United States, students in India enter medical school after graduating high school. The criterion for admission into medical school is based upon a national written examination. India has a large number of schools and applications. Because of this, the single written examination is generally the criteria for admission [1, 6].
Upon completion of medical school, students earn a Bachelor of Medicine and Bachelor of Surgery (MBBS) degree. Following completion of basic medical training, students enter a 1-year Compulsory Rotating Residential Internship (CRRI). This program is similar to a rotating or transitional internship. Upon successful completion of the CRRI, medical students receive medical college diplomas [1, 6].
Medical school candidates are exposed to a wide variety of specialty areas that serve the needs of the country prior to making their selection of career. This differs from the American experience, in which a medical student generally applies for specialty training at the end of their third year in medical school.
In order to apply for residency specialty training, MBBS graduates must pass a national-level and/or state-level “postgraduate entrance exam”—a written exam that is the deciding factor for placement in postgraduate training.
Basic Surgical Education
Currently, residents in India can obtain orthopaedic surgery education via three main pathways: a university-based Masters (MS Orthopaedics) program, a Diplomate of National Board (DNB) program, and a Diploma in Orthopaedic Surgery (D.Ortho) program [1, 5, 6, 7].
Residents can earn a Master of Surgery degree in orthopaedic surgery, MS (Orthopaedics), upon successful completion of a 3-year orthopaedic specialty training program. In order to gain eligibility for an exit examination, residents must pass the standard national curriculum for resident exposure and education, and successfully complete a required thesis. The curriculum covers all aspects of general orthopaedic surgery, including pathology (which itself deals with conditions especially common in India, in particular infections and tuberculosis). According to the Medical Council of India, there are 225 MS (Orthopaedics) training programs available to residents. For the 2012–2013 years, 919 slots were available for the first-year postgraduate orthopaedic class . That number is quite small when considering the population of the country. Just what the “right number” might be is hard to discern when considering the size and scope of the entire Indian health system.
Like other countries, orthopaedic surgery is a popular specialty for postmedical school education, and the need for further specialists is warranted. Candidates who fail to earn admission into the MS programs can also apply for the 3-year Diplomate of National Board (DNB) program in nonuniversity-affiliated hospitals. In order to gain enrollment in DNB courses, MBBS students must take a national-level common entrance examination conducted by National Board of Examination. D.Orth candidates who wrote a thesis and have 2 additional years of education may also be eligible to take the DNB exams. Qualified MS (Orthopaedics) candidates may take the exit examination for DNB without any further training. The course structure is on par with the Medical Council of India’s recognized courses .
Recognizing the overwhelming interest in obtaining a MS (Orthopaedics) degree, the Medical Council of India supervises another pathway for entrance into orthopaedics called the Diploma in Orthopaedic Surgery (D.Orth) program. In 2013, the 2-year D.Orth program offered 110 courses with 309 first-year seats available. This program is to provide graduates who will provide care in areas of limited resources with a more limited scope than seen with the 3-year curriculum.
Further training as a senior resident in orthopaedic surgery is available in few select states/universities/hospitals. Senior resident training runs for a further 3 years, and is less structured than the MS education. The senior resident will care for patients along with faculty members at their hospital. The senior resident is also given more autonomy to run their own operating room and clinic, with indirect supervision of a faculty member. Admission for a senior residency is based on recommendations and interviews. Each institution is slightly different, but generally, it takes 3 calendar years to complete a senior residency. There are even fewer senior resident positions available than those at the MS-level program. Therefore, not all Masters graduates will receive further training.
Candidates who did not succeed in obtaining a senior resident position are also deemed to be orthopaedic surgeons and are authorized to practice the specialty. However due to their insufficient surgical experience many will opt for a junior staff position under the indirect guidance of a senior surgeon. Others may work in a less served area practicing office orthopaedics and a few basic surgical procedures [1, 5].
Fellowship training, beyond Senior Residency, is offered by the National Board of Examinations in hand and microvascular surgery, spine, and trauma. These 2-year fellowships are available postgraduation, but usually have no more than ten spots available for the entire country [1, 5].
There are a number of strengths to Indian orthopaedic medical education. Senior orthopaedic residents work in a more traditional model. They will run their own operating room while in the supervision of a consultant. This allows for autonomy and developing surgical skills in a safe environment. As a senior resident’s skills progress, he or she is given more autonomy. Under this system, the senior resident must demonstrate the ability to care independently for patients.
The Indian medical education is provided in English, and both junior and senior residents are exposed to the world’s leading medical journals for orthopaedic surgery. Additionally, textbooks are printed in English, allowing for a broad exposure to world orthopaedic surgery. Since (MS Orthopaedics) training is provided in high-patient-population institutions, the trainee learns how to utilize his or her basic skills in decision making and handling large patient loads.
As orthopaedic care in India has become more complex, Indian orthopaedic surgeons have noted that the Masters-level training in India is not comprehensive enough, and some graduates may have insufficient training to practice independently. Future modifications should include a longer residency program (possibly adding 1–2 years of mandatory education), and create mechanisms (such as board certification processes) that ensure physician competence. Furthermore, emphasis on preparing graduates to care for common problems in India, such as tuberculosis or neglected fractures, could be improved. These further educational opportunities for MS/DNB graduates must be readily available [5, 6].
Given the relative shortage of doctors to the population, the limited resources available to care for patients, and the wide variety of diagnoses orthopaedic surgeons are expected to treat, Indian education has made tremendous strides to provide the best for the most people.
The UK includes a population of 64.1 million people (2013) within its borders. There is an abundance of physicians in the UK (2.81/1000 population) vs. the United States (2.45/1000 population) [2, 4]. Healthcare in the UK is largely provided by the National Healthcare Service (NHS) which also provides the financing of graduate medical education. Graduate medical education in the UK recently restructured with the goal of improving trainee experience. In 2005, the Modernizing Medical Careers program changed the organizational structure of all postmedical school training in the UK due to concerns about excess length of training and a lack of supervision . The goals were to include standardization of education and training to produce “high-quality, well-trained, accredited doctors.” A more formalized structure of feedback and assessment has also been implemented to document the progress of trainees . Additionally, the European Union’s European Work Time Directive (EWTD) reduced the number of hours any employee could work (including those in graduate medical education training)—from 56 to 48 h per week .
Orthopaedic Training : The Foundation Years
Medical school is a 5-year program, beginning after secondary (high) school. Graduates obtain a “Bachelor of Medicine, Bachelor of Surgery” which is abbreviated in a variety of ways (MB BS, BM BCh, MB BCh, MB BCh BAO, etc.), depending on the institution. All are equivalent degrees, which allow the graduate to be qualified for further education.
Orthopaedic registrar education is divided into three phases: the “foundation years,” core surgical training, and then higher surgical training. In the foundation years (FY1–2), the new physician obtains further education regarding basic patient care skills. These years (Fig. 2.1) are similar to an internship in the United States, with exposure to different medical areas, providing broad exposure to other medical conditions. During the first 2 years, the trainee is eligible to take Part A of the Member Royal College of Surgeons exam.
Orthopaedic education in the UK is described as Trauma and Orthopaedic (Tr & Orth), recognizing the need to care for patients who have sustained trauma, and the large dependency on the healthcare system to care for patients with fractures .
Core Specialty Education
The next level of training, called core specialty training (CT1 and CT2), is appointed by competitive interview. Core specialty training begins after the foundation years, and is considered the initial surgical specialty training. There are run-through programs, in which the candidate progresses directly to the later years of surgical training. Those who are in run-through programs are designated as specialty trainees (ST) instead of CT1 and CT2. Specialty trainees may rotate in no more than two related surgical fields for up to 6 months each. The first year (CT1 or ST1) focuses on the care of trauma patients, the management of simple fractures, and principles of both internal and external fixation. The second year, CT2/ST2, builds on the previous year, developing more extensive surgical skills for fracture fixation (intra-articular, open, and hip fractures for example), and initial exposure to elective types of procedures. During the second year, the trainee is eligible to take Part B of the Member Royal College of Surgeons exam, consisting of a patient-based simulation exam (objective structured clinical exam) .
Alternate Pathway if Unsuccessful Core Training
At the end of CT2, trainees who have been unsuccessful in passing the Member Royal College of Surgeons exam or who have not gained a National Training Number for ST3–8 training may apply for a further year in core training for experience, undertake a clinical fellowship (junior posts which do not have official recognition for training), or apply for a Specialty Doctor/Non-Consultant Hospital Doctor post. Specialty Doctor posts are permanent subconsultant career posts. Doctors who have worked in these posts for several years can apply to the General Medical Council for Specialist registration if they have equivalent experience to a day 1 Consultant, and have passed the Fellow of the Royal College of Surgeons (FRCS) (Tr & Orth) examination. This, however, is a lengthy process and the award is by no means automatic .