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Orthopaedic surgeons worldwide must overcome hurdles in their career path
Orthopaedic surgeons throughout the world face a number of challenges en route to becoming certified and recognized as authorities in their area of practice. As the amount of information disseminated at orthopaedic and other scientific meetings seems to increase each year, so do our expectations of surgeons graduating from medical school.
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To aspire to become an orthopaedic surgeon, one has to first be accepted into a university to study for a medical degree. This may be an undergraduate or graduate program, with the former being typically 5 or 6 years, and the latter for 4 years. Entry into medical degree programs itself is extremely competitive in most countries.
The next hurdle is the training program after obtaining a medical degree. In the English-speaking countries, the candidate may or may not need to do a year of internship before entering into the training program. Entry is by no means automatic, as the competition is generally tough.
In countries where there is some form of national health service such as in Great Britain, Canada, Singapore and Hong Kong, the number of training posts in all medical specialties, including orthopaedics, is carefully planned and limited. The mode of selecting trainees can also be controversial, as was the case with Great Britain about a year ago, when the whole process was so flawed that it had to be abandoned and repeated, with administrators and politicians resigning because of the farce.
The training program varies from 4 to 6 years, at the end of which the trainees usually choose a subspecialty and undergo a further year of “fellowship” training in that subspecialty.
Continuing education
There is usually some form of certification at the end of all that, after which the trainee becomes a full-fledged orthopaedic surgeon. The certification requires trainees to have continuous assessment during the training period and to undergo a final assessment process, either in the form of a written examination with varying forms and proportions of Objective Structured Clinical Examination, or a written examination plus a real clinical examination including actual patients.
But that is not the end of the hurdles. A practicing orthopaedic surgeon needs to undergo regular continuing medical education (CME) to ensure that the knowledge gained from medical school and postgraduate training programs will be updated continually, because of the rapidity with which medical knowledge changes and accumulates. The method of regulation, amount and scope of CME needed, as well as how to ensure compliance, varies from countries to countries. In some countries, it is linked to a reissue of practicing certificates.
A more in-depth and formative version of this is continuing professional development (CPD). The Hong Kong Academy of Medicine has defined CPD as development of competencies relevant to the practice profile of a practitioner that may change over the years. Likewise, professional development endeavors are directed at enhancing his or her quality of care and the delivery of safe standard of practice. While CME is educator-centered, has little direct impact on improving professional practice and involves passive learning, CPD is learner-focused, is good for quality management in terms of changes, and involves active learning.
Is recertification necessary?
Yet another hurdle that has been discussed widely and practiced in a limited way in some countries is recertification. In these cases, the practicing orthopaedic surgeon has to undergo reassessment of his or her clinical competency periodically.
Many controversial issues surround the issue of recertification, including defining the scope of the reassessment, as many practitioners would have become more and more specialized in their practice after many years. For example, would a hand surgeon or shoulder surgeon be required to be reassessed in general orthopaedics? What if the recertification is unsuccessful? Will the right to practice be suspended? Is there any recourse or re-education for another reassessment?
Likewise, malpractice lawsuits are becoming more and more of an issue not only because they impact the costs that physicians must pay for malpractice insurance, but also the psychological stress orthopaedists face in dealing with them.
Academicians have hurdles, too
For orthopaedic surgeons who wish to pursue an academic career, there are, of course, additional hurdles. Whereas an academic orthopaedic surgeon used to be able to advance in his or her career by doing systematic, well-planned clinical case studies and perhaps producing some surgical technical innovations, the demand on the present day clinician-scientist is much more stringent.
The surgeon has to pursue serious basic research, which in the 1970s and 1980s was grounded mainly in biomechanics. But in the 1990s and the recent decade, biomaterials, tissue engineering, molecular biology and genetics have become the necessary areas. The clinician-scientist has to take significant time to learn or relearn these basic sciences, such as doing a PhD program, in order to be able to advance in his academic ladder.
All these hurdles have evolved with time. They are there to ensure that the quality of the orthopaedic care rendered to patients by orthopaedic surgeons is commensurate with the highest possible standards, as well as with the rising demands of patients who are much more knowledgeable about medical care than their parents and grandparents.
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- John C.Y. Leong, FRCS, MCAS, is an orthopaedic spine surgeon and president of The Open University of Hong Kong, Kowloon, Hong Kong, China. He is an editor for Orthopaedics Today International. He can be reached at jcyleong@ouhk.edu.hk.