Comparing the two pathways to becoming an Orthopedic ...

Comparing the two pathways to becoming an Orthopedic surgeon in both the US and New Zealand

Secondary Education PostSecondary Education

Medical School

U.S.A. Standard high school education 3-4 years - 4 year undergraduate general or specific subject degree - Bachelor of Arts / Sciences - MCAT required - 4 years total. 2 years of classroom basic sciences, plus 2 years of ward based training in most specialties - Graduate with Medical Doctor degree (MD) - 3 part USMLE license exams

New Zealand Standard high school education 4 years Much less frequently done, but is similar in structure as 4 year undergraduate degree

Direct entry from secondary school or completion of undergraduate degree Six years of medical training First year is pre-medical course Years 2-3 are pre-clinical 4th to 6th years similar to 3-4 in USA Graduate with Bachelor of Medicine and Bachelor of Surgery (MBChB)

Age 17-18 22

24 (NZ) 26 (US)

Internship / Foundation Years

Rarely done. If so is one year preliminary program in general surgery with transition to residency Must re-enter the match once more with medical school graduates to take position as 1st year resident Maximum number of years to reapply

Junior

None

Residency

Residency Fellowship

Take specific Orthopedic Inservice Training Exam yearly Take Orthopedics specific board after graduation Must complete minimum requirements in surgeries, patient care, education, etc 80-100 hour work weeks Not required, but becoming more and more common - ~ 90% enter fellowship - Where most training occurs

Pre-vocational training as a medical graduate. Certified under the Education Committee of the MCNZ Become a surgical trainee, rotate through various specialties including Anesthesia, Surgery Typically takes 2 years after completion of exams, rarely 1 year. Highly dependent on supply/demand Can take as many years as wanted Must have completed the GSSE General Surgical Sciences Exam before applying Enter into the field of Orthopedics as a Junior resident, equivalent to 1st year of Orthopedics Residency. Mostly floor duties, 1 day per week in operating theatre MCNZ determines the qualifications / requirements needed. Rotate through a variety of NZ hospitals Annual Review by the NZOA Committee 48-60 hour work weeks Royal Australasian College of Surgeons

26-28 (NZ) 27 (US)

28-30 (NZ)

33-35 (NZ) 31 (US)

Fellowship of Royal Australasian College of Surgeons Work independently as Orthopedic Surgeons in the fellowship of their choosing Course required as fellow in professional development

34-36 (NZ) 32 (US)

Attending / Consultant and Beyond

Earn money for the specific procedures/visits performed, significant documentation required

- Insurance largely determines eligibility for procedures

Vocationally registered as an Orthopaedic Surgeon with the New Zealand Medical Council

How the international elective will impact my career as a future doctor:

This rotation was valuable in so many ways. Most importantly, the contacts I made while in New Zealand I will keep for the rest of my life. Both residents and attendings in New Zealand I was able to make strong friendships with, because I was not under such pressure for the best evaluation that I was able to get to know them much more thoroughly. Much of the research that is performed in international Orthopedics, as well as standards for certification and guidelines for treatment come from institutions based in the United States. That being said, many of my New Zealand colleagues frequently visit the US for conferences, which will be great opportunities to re-convene. I will also now have references for even the possibility of a fellowship opportunity in New Zealand once my own residency training has completed.

Understanding how Orthopedic care is delivered in another country is the other main way that my future career as a surgeon will be impacted. In the United States, insurance companies dominate the health care industry and determine much of what Orthopedic procedures are performed. In the setting of various elective surgeries, such as total joint replacements, a person with insurance will likely have to exhaust non-operative management of their symptoms first, but then will have elective operations covered up to a certain point. In New Zealand, the country's health care runs under a split between publicly funded and privately (insurance) funded care. In New Zealand, if a person does not have private insurance, then they are subject to just the care that can be provided by their hard earned tax dollars. The same elective total joint replacement that they would want in the US, would take much longer to receive if they are only utilizing public funding. It is only when patients supplement their coverage with private insurance do they receive as timely of Orthopedic care for elective surgeries as they would in the US. On the other hand, for traumatic Orthopedic needs, the publicly funded care in New Zealand has its advantages. Any patient, whether New Zealand citizen or otherwise, will receive all necessary care, surgery, hospital needs, medication, etc as long as their traumatic injury happened in New Zealand. In the US, traumatic injuries are almost covered similarly to elective procedures, where those with insurance end up with much less of a bill at the end. How a different country handles Orthopedic needs of patients helps to not only better helps me understand how the US bills and manages these needs, but also helps to identify pros and cons to each system that could be useful for impacting change in public health policy. I now have a better appreciation for the health care system we have in the United States for handling Orthopedic needs of patients, but also appreciate a country that truly cares about the acute needs of any person in their country, willing to provide whatever they need for medical coverage.

Training variation in the path to becoming an Orthopedic Surgeon:

I have outlined above the key differences in training amongst the two nations in the long and difficult path one must take to become an Orthopedic Surgeon. The main differences between the two are the length of time to train, the intensity of the training, and whether general medical experience impacts future Orthopedic practice.

Getting into and completing medical school in New Zealand takes much less time than in the US. However, if one wishes to become a surgeon in New Zealand, they must complete several years of general training in various surgical fields prior to entering a comparable residency program like in the US. Typically those in the path towards Orthopedics in New Zealand complete 2 years after medical school as a House Surgeon, where operating is actually quite rare, and experience gained is mostly in floor duties and general medical knowledge. After this, one can apply to become a Junior Registrar (resident) in their field of choice, which is comparable to an intern year of Orthopedics in the US. After two or so years as a junior resident, and after proper examinations, one can then enter a similar 5 year training program for residency. Fellowship and consultant training is nearly identical among the two countries.

After interviewing Dr. Chris Fougere, as well as residents, junior residents, and even house surgeons about my topic, I was able to learn much about each step in this process. Coming from Dr. Fougere himself, he was quite envious of the training regime in the US for Orthopedic Surgeons, having a quicker residency training program that allows someone to finish by age 3032 and start their career. Like in the US, when an Orthopedic Surgeon in New Zealand is operating at the attending level, they become so specialized that expertise in anything besides Orthopedics is almost unnecessary. At each hospital, physicians have access to various specialized fields and can consult if necessary. That being said, Dr. Fougere explained how the general training he received as a house surgeon especially, he no longer uses nor remembers at this stage in his career. Current residents gave me similar input, in that they just felt as though the road was too long for such a similar end point. Nearly everyone I spoke to enjoyed having a shorter work week, but would prefer to have a shorter overall training period with more intense work hours as is done in the US.

Profound Cultural and Clinical Experiences:

A patient entered our Orthopedic service that Dr. Fougere had picked up. This was Ms. K, a 65 year old Asian woman who had quite a complicated past medical history. She had previously fractured her femur, and because of underlying medical conditions had difficulty healing her previous injuries. After multiple trips to the operating theatre, and complications with healing of her fracture with infection, she presented to our service with minimal hope for recovery. Dr. Fougere, although somewhat hesitant, took on this complicated patient, knowing that operating would be quite risky, and decided to move forward with attempting a definitive fixation technique. This was quite admirable, since not many of his colleagues were really very interested in operating on this patient with her past medical history, and likelihood of needing repeat operations. Examining this patient was quite impactful, the area around her right hip was so scarred and damaged from her previous operations that there were deep indentations in her soft tissue and scars that were quite apparent. So Ms. K presents to our service with continuing complication of her right hip fracture, with MRSA infections of the bone. This is quite damaging to the surrounding structures and leaves few options for healing. It was then that Dr. Fougere used a technique I had heard of before, but had not yet seen in my experience in Orthopedics, and that was to use an antibiotic impregnated cement spacer to temporarily hold her leg in position. The advantage of using this was that it slowly elutes antibiotics to help kill bacterial pathogens inside, while also providing structural stability to the leg while a definitive operation for fixation can be postponed to a later date. This patient handled the operation well, and remained closely monitored on the Orthopedic unit at Auckland City hospital while I was on the service of Dr. Fougere. It was just so amazing to me that Dr. Fougere took on such a challenging task, of handling a patient he had never met, but knew would be so very complicated moving forward, but wanted to find the best technique to keep his patient mobile and make an attempt at healing her long term injuries.

The Maori population, and the Polynesian population in general, makes up a substantial portion of the general population of New Zealand. The profound cultural experience I had during my experience in New Zealand was with treating patients of this demographic with Orthopedic needs. As in the US, the Orthopedic team handles patients with bony traumatic injuries, as well as bone and soft tissue infections. In New Zealand, the Pacific Islander population has an unusually high rate of infection in the setting of Orthopedic trauma. I found this just fascinating, as there were substantially higher numbers of patients presenting with infections than I had seen at any other institution. To my surprise, I was informed by the Orthopedists that this population is naturally colonized with different skin and other flora that makes them more susceptible to developing infectious complications. In general, this population also has higher rates of heart disease and diabetes, which may also be contributing to these outcomes. But overall, I just found

it so fascinating to work with this population so much and see how much of an Orthopedic practice can be made up of infectious complications in the Pacific Islander demographic.

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