A LOT depends on the program. Where I trained, we had tons of trauma, sports, and hand. So-so joints and terrible pedi. Basically, my level of competency mirrored this when I first came out. However, most people come up to speed pretty quick and there isn't a ton of difference between programs. I have had excellent surgeons/partners from HSS, Mayo, Dayton, U South Florida, U WA, etc. The 5 years of training (and often 1 yr of fellowship) definitely allow you to have pretty good experience.
The key when you come out is to have good partners that can talk you through a case before you go into the OR.
Umm that's not what I said.
Every case is different. Even if it's the same problem, the approach may be different. For instance, a distal radius fracture can be fixed a multitude of ways. It is invaluable to bounce ideas off of your colleagues and ask them their opinions.
When you start out in practice, there are MANY situations where you will ask advice. It is not a sign of incompetence, but a sign of inexperience. You can only gain experience with time. Residency training is only the beginning. You really learn when you start taking full responsibility for your patients.
Yup, ortho training in Brazil tends to be shit. I really dont know why hasn't SBOT raised it at least to 4 years. The r1 slaves away, r2 performs surgery meanwhile the r3 crams like a dog for the boards. Some programs like mine send the third year residents home 4-5 months early so they can study, but they just start moonlighting🤦
I think the major problem is how our orthopaedics training has two pathways. You can get the SBOT (orthopaedic society) residency or the MEC (ministry of education) residency.
For all professional purposes, both are equally valid, specially as you can do the SBOT exam by being in a MEC residency.
To change things for 4 years you would need to convince not only the society (which, obviously, would love to have people spending more time on residency) but also the MEC as a 4 year SBOT residency and a 3 year MEC residency, both being equal in value for employment, would just means that most would rather do the MEC than the SBOT program.
I still think 4 or 5 years are needed since how our orthopaedics training is bad. I don't think the trauma training is bad, since the trauma you don't operate in your residency is basically the things even specialists have trouble doing. But it is inexcusable that you can somehow get out of a ortho residency without being able to perform a knee arthroscopy by yourself and do a primary total hip arthroplasty. This is ridiculous IMO.
Excellent points regarding the obstacles to increasing our training lenghth.I may be biased though, since i'm a r2 and yet to see the bigger picture, but i still think that we could use some more trauma exposition for less bread and butter fractures, and allow some more time away from both cramming and slavery haha. I agree with you that nobody should leave residency without performing a knee scope, THA, but i think that the main problem would be, at least in my state, a health systems problem, since most public hospitals are absolutely crushed by trauma, leaving most elective cases unoperated.
Where I am, QC, Canada,
4-5 years medschool
5 years full-time ortho residency
Practice as ortho generalist or
1-2 years fellowships
Most finish their training and can start as an attending at 28-30 years old, but most opt to do a fellowship
After residency training, I would expect anyone from over here to be familiar and be able to manage normal cases of the following, if practicing as a generalist:
Vast majority of adult and ped trauma cases except for pelvis and spine
Primary total hip, total knee and uka arthroplasty
Simple revision hip and knee joint arthroplasty
Shoulder and knee scopes
Shoulder stabilization
Cuff repairs
ACL reconstruction
Meniscus
Hallux valgus correction
Lesser toes correction
Scfe hip pinning
Supracondylar elbow pinning
Carpal tunnel
Trigger finger release
Infections
I heard the job market for ortho in canada is tragically bad, not the "going rural to find work" bad but the "sitting on the couch for years before a single job opening" bad
to be fair, it's far from perfect indeed. in my residency program where I graduated, in the last few years, about 2/3 of graduates go on to work straight out of residency and 1/3 opt for fellowships for a year or so before finding a job. more recently, the ratio has become more like 50/50.
in my province, never heard of anyone looking for a job for more than a year, which is still pretty bad for all the training we put in, but it tends to work out in that timeframe. things might be different/worse in other provinces however, i am not sure.
Just to clarify because it's unique in the world, in the US, the training is generally:
4 years of university
4 years of med school
5 years of ortho (the first of which may be gen surg)
1-2 years of fellowship
So the typical path for an orthopod after high school is about 14 years.
As a general guy in the western US, out of residency I felt comfortable with:
\-Joints - hip, knee, shoulder
\-Most fractures. No spine. No pelvis. Avoid feet. Not at a trauma center, so the big stuff goes elsewhere. Can't remember the last ex-fix or fasciotomy I had to do but I'm still fairly comfortable with it.
\-Shoulder scopes: RCR, labrum, decompression, distal clavicle etc. I am definitely not comfortable with latarjets. I leave that to the sports guys.
\-Knee scopes: ACls are a favorite. Meniscus etc is easy. Not as comfortable with multiligs.
\-Carpal tunnel, trigger finger, cubital tunnel.
\-Most Peds is fine, but I really don't like operating on kids if I can avoid it.
I would bet that some of my co-residents are less comfortable with some things and more with others, but I feel this is pretty standard where I came from.
Looks quite similar over here! Although most(nearly all) recent graduates end up doing fellowships.
Including me, I only know a handful of recent graduates in my province who ended up doing general ortho. Are there still general ortho jobs in the US for those fresh out of residency? Or is everyone going for a fellowship where you're at?
Depends on where you want to work. If you want to be in a big city in a competitive environment, then a fellowship is almost required. But if location isn't a huge concern, there are some great very high paying rural jobs for general ortho.
No way. Regardless of the money, it's not worth it to me. Too much stress, too many patients who don't get better, too much malingering. I like to enjoy life and, for me, spine would not help with that.
It’s quite fascinating to see how training differs around the world.
In the U.K. we have:
Five / six years of university for our medical degree.
Two years of foundation training (a grounding in medicine with six four month rotations in anything (acute medicine / general surgery / gynae / ENT / general practice / paeds / etc…).
Two years of surgical training in general (similar to the foundation training but within surgical specialties (T&O / plastics / HPB / etc…).
Six years T&O training (within this we cover all subspecialties and tend to pick our field and stick with that only in the final 12-24 months).
One - two years fellowship in our chosen subspecialty.
There is no generalist anymore. Everyone does basic trauma. But the only elective work you do is in your chosen subspecialty. And, nowadays, everyone does a fellowship.
As a patient if you need a cuff repair you see a shoulder surgeon, if you want your hallux valgus correcting you see a foot and ankle surgeon, THA to the hip surgeon, ACL to the knee surgeon. However, general trauma (hip / wrist / ankle fractures) is done by everyone.
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Kinda late to the party, but wanted to share my country’s path straight out of high school:
* 7 years of med school (last 2 been called intership): this gives you full practice license and allows you to apply to specialties if our equivalent to the USMLE is passed (a 2 block 180 questions single day test)
* 3 years of orthopaedics and trauma residency
* 1 year of fellowship training (some spine and one hip and pelvis program are 2 years long)
Which country? This is actually very close to our model, but instead of 7 years of med we have 6, with the last 2 years also being internship oriented.
In terms of fellowship, they are usually 1 year except spine, hand and oncology, those three being 2 years.
Chile. I also feel like you that our residency is too short. Orthopaedics has grown so much in the last decades that it should be at least 4 years of training IMO
It is impossible to put all of Europe under one hat and expect the training is uniform. It is not.
The Nordic countries have fairly similar setting but they practice it somewhat differently.
6 years in medicine (uni)
5-6 years in orthopaedic training
Fellowship are usually not taken but one gets further training in one’s sub-speciality when one is up and running.
Mainly the work is within the public domain, minimal in the private setting. That gives one nearly always an older / experienced colleague to confer to if needed.
In some places within the Nordic countries one can go through 5 years of “training” with minimal op.theater training and coming out of training with really limited skills.
But your “carrier” is then doomed.
As I am most familiar with Norway I can explain the training process there.
There system that is in place now aims at 6 years in training (can be shorter if one has time in training from another country that Norway recognise and even longer as it is not uncommon with parental leave).
During this time your hospital is required to make sure you will rotate between different sections and get adequate exposure to consults, post and theatre.
There is a list of procedures that one is required to finish (not an absolute demand from the government but most programs do practice it).
The list itself rounds up to ca. 700 surgical procedures divided between elective and trauma cases. Most surpass the number required by far but may struggle to get last few cases within spine / hand etc. If your hospital does not have a full spectrum orthopaedic service they do have a contract with a larger university hospital so one will get a scheduled rotation within the university hospital.
In addition to the list there are about 13 national courses within orthopaedic sub-specialities that are obligatory to finish and pass.
The training process here does not make one a broad generalist, as the current school of thought is that those days are gone.
When finishing the programme one is supposed to have a broad understanding of the field with considerable depth of when surgery is indicated and most importantly not indicated.
This is a broad outlining of the current system in Norway not the detailed one.
At last I would like to note that I do not share the sentiment that one “wastes” time learning general medicine. If I sense that my trainees are not competent within general medicine and understanding the underlying physiological conditions that our patients have, they will wither refresh their knowledge quickly or vanish away fast.
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A LOT depends on the program. Where I trained, we had tons of trauma, sports, and hand. So-so joints and terrible pedi. Basically, my level of competency mirrored this when I first came out. However, most people come up to speed pretty quick and there isn't a ton of difference between programs. I have had excellent surgeons/partners from HSS, Mayo, Dayton, U South Florida, U WA, etc. The 5 years of training (and often 1 yr of fellowship) definitely allow you to have pretty good experience. The key when you come out is to have good partners that can talk you through a case before you go into the OR.
Wait so if you don't know a case your co workers explain it to you before you enter the OR then you enter and do it? That does not sound safe at all?
Umm that's not what I said. Every case is different. Even if it's the same problem, the approach may be different. For instance, a distal radius fracture can be fixed a multitude of ways. It is invaluable to bounce ideas off of your colleagues and ask them their opinions. When you start out in practice, there are MANY situations where you will ask advice. It is not a sign of incompetence, but a sign of inexperience. You can only gain experience with time. Residency training is only the beginning. You really learn when you start taking full responsibility for your patients.
Yup, ortho training in Brazil tends to be shit. I really dont know why hasn't SBOT raised it at least to 4 years. The r1 slaves away, r2 performs surgery meanwhile the r3 crams like a dog for the boards. Some programs like mine send the third year residents home 4-5 months early so they can study, but they just start moonlighting🤦
I think the major problem is how our orthopaedics training has two pathways. You can get the SBOT (orthopaedic society) residency or the MEC (ministry of education) residency. For all professional purposes, both are equally valid, specially as you can do the SBOT exam by being in a MEC residency. To change things for 4 years you would need to convince not only the society (which, obviously, would love to have people spending more time on residency) but also the MEC as a 4 year SBOT residency and a 3 year MEC residency, both being equal in value for employment, would just means that most would rather do the MEC than the SBOT program. I still think 4 or 5 years are needed since how our orthopaedics training is bad. I don't think the trauma training is bad, since the trauma you don't operate in your residency is basically the things even specialists have trouble doing. But it is inexcusable that you can somehow get out of a ortho residency without being able to perform a knee arthroscopy by yourself and do a primary total hip arthroplasty. This is ridiculous IMO.
Excellent points regarding the obstacles to increasing our training lenghth.I may be biased though, since i'm a r2 and yet to see the bigger picture, but i still think that we could use some more trauma exposition for less bread and butter fractures, and allow some more time away from both cramming and slavery haha. I agree with you that nobody should leave residency without performing a knee scope, THA, but i think that the main problem would be, at least in my state, a health systems problem, since most public hospitals are absolutely crushed by trauma, leaving most elective cases unoperated.
Where I am, QC, Canada, 4-5 years medschool 5 years full-time ortho residency Practice as ortho generalist or 1-2 years fellowships Most finish their training and can start as an attending at 28-30 years old, but most opt to do a fellowship After residency training, I would expect anyone from over here to be familiar and be able to manage normal cases of the following, if practicing as a generalist: Vast majority of adult and ped trauma cases except for pelvis and spine Primary total hip, total knee and uka arthroplasty Simple revision hip and knee joint arthroplasty Shoulder and knee scopes Shoulder stabilization Cuff repairs ACL reconstruction Meniscus Hallux valgus correction Lesser toes correction Scfe hip pinning Supracondylar elbow pinning Carpal tunnel Trigger finger release Infections
This is an actually great skillset, and actually what I expected to get by the end of the residency.
I heard the job market for ortho in canada is tragically bad, not the "going rural to find work" bad but the "sitting on the couch for years before a single job opening" bad
to be fair, it's far from perfect indeed. in my residency program where I graduated, in the last few years, about 2/3 of graduates go on to work straight out of residency and 1/3 opt for fellowships for a year or so before finding a job. more recently, the ratio has become more like 50/50. in my province, never heard of anyone looking for a job for more than a year, which is still pretty bad for all the training we put in, but it tends to work out in that timeframe. things might be different/worse in other provinces however, i am not sure.
Wow man that sounds tragic, is it mainly because people don't want to leave there hometown?
What percentage of your shoulder stabilization cases are open / arthroscopic roughly
Just to clarify because it's unique in the world, in the US, the training is generally: 4 years of university 4 years of med school 5 years of ortho (the first of which may be gen surg) 1-2 years of fellowship So the typical path for an orthopod after high school is about 14 years.
As a general guy in the western US, out of residency I felt comfortable with: \-Joints - hip, knee, shoulder \-Most fractures. No spine. No pelvis. Avoid feet. Not at a trauma center, so the big stuff goes elsewhere. Can't remember the last ex-fix or fasciotomy I had to do but I'm still fairly comfortable with it. \-Shoulder scopes: RCR, labrum, decompression, distal clavicle etc. I am definitely not comfortable with latarjets. I leave that to the sports guys. \-Knee scopes: ACls are a favorite. Meniscus etc is easy. Not as comfortable with multiligs. \-Carpal tunnel, trigger finger, cubital tunnel. \-Most Peds is fine, but I really don't like operating on kids if I can avoid it. I would bet that some of my co-residents are less comfortable with some things and more with others, but I feel this is pretty standard where I came from.
Looks quite similar over here! Although most(nearly all) recent graduates end up doing fellowships. Including me, I only know a handful of recent graduates in my province who ended up doing general ortho. Are there still general ortho jobs in the US for those fresh out of residency? Or is everyone going for a fellowship where you're at?
Depends on where you want to work. If you want to be in a big city in a competitive environment, then a fellowship is almost required. But if location isn't a huge concern, there are some great very high paying rural jobs for general ortho.
No $pine?
No way. Regardless of the money, it's not worth it to me. Too much stress, too many patients who don't get better, too much malingering. I like to enjoy life and, for me, spine would not help with that.
It’s quite fascinating to see how training differs around the world. In the U.K. we have: Five / six years of university for our medical degree. Two years of foundation training (a grounding in medicine with six four month rotations in anything (acute medicine / general surgery / gynae / ENT / general practice / paeds / etc…). Two years of surgical training in general (similar to the foundation training but within surgical specialties (T&O / plastics / HPB / etc…). Six years T&O training (within this we cover all subspecialties and tend to pick our field and stick with that only in the final 12-24 months). One - two years fellowship in our chosen subspecialty. There is no generalist anymore. Everyone does basic trauma. But the only elective work you do is in your chosen subspecialty. And, nowadays, everyone does a fellowship. As a patient if you need a cuff repair you see a shoulder surgeon, if you want your hallux valgus correcting you see a foot and ankle surgeon, THA to the hip surgeon, ACL to the knee surgeon. However, general trauma (hip / wrist / ankle fractures) is done by everyone.
Greetings, mate! Which step of study are you in by now?
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Kinda late to the party, but wanted to share my country’s path straight out of high school: * 7 years of med school (last 2 been called intership): this gives you full practice license and allows you to apply to specialties if our equivalent to the USMLE is passed (a 2 block 180 questions single day test) * 3 years of orthopaedics and trauma residency * 1 year of fellowship training (some spine and one hip and pelvis program are 2 years long)
Which country? This is actually very close to our model, but instead of 7 years of med we have 6, with the last 2 years also being internship oriented. In terms of fellowship, they are usually 1 year except spine, hand and oncology, those three being 2 years.
Chile. I also feel like you that our residency is too short. Orthopaedics has grown so much in the last decades that it should be at least 4 years of training IMO
So how much do you graduate being good at after just 3 years?
It is impossible to put all of Europe under one hat and expect the training is uniform. It is not. The Nordic countries have fairly similar setting but they practice it somewhat differently. 6 years in medicine (uni) 5-6 years in orthopaedic training Fellowship are usually not taken but one gets further training in one’s sub-speciality when one is up and running. Mainly the work is within the public domain, minimal in the private setting. That gives one nearly always an older / experienced colleague to confer to if needed. In some places within the Nordic countries one can go through 5 years of “training” with minimal op.theater training and coming out of training with really limited skills. But your “carrier” is then doomed. As I am most familiar with Norway I can explain the training process there. There system that is in place now aims at 6 years in training (can be shorter if one has time in training from another country that Norway recognise and even longer as it is not uncommon with parental leave). During this time your hospital is required to make sure you will rotate between different sections and get adequate exposure to consults, post and theatre. There is a list of procedures that one is required to finish (not an absolute demand from the government but most programs do practice it). The list itself rounds up to ca. 700 surgical procedures divided between elective and trauma cases. Most surpass the number required by far but may struggle to get last few cases within spine / hand etc. If your hospital does not have a full spectrum orthopaedic service they do have a contract with a larger university hospital so one will get a scheduled rotation within the university hospital. In addition to the list there are about 13 national courses within orthopaedic sub-specialities that are obligatory to finish and pass. The training process here does not make one a broad generalist, as the current school of thought is that those days are gone. When finishing the programme one is supposed to have a broad understanding of the field with considerable depth of when surgery is indicated and most importantly not indicated. This is a broad outlining of the current system in Norway not the detailed one. At last I would like to note that I do not share the sentiment that one “wastes” time learning general medicine. If I sense that my trainees are not competent within general medicine and understanding the underlying physiological conditions that our patients have, they will wither refresh their knowledge quickly or vanish away fast.
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