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SICOT e-Newsletter

Issue No. 70 - October 2014

Articles by SICOT Members

WOC Surgical Training Proposals

Michael Laurence
SICOT Emeritus Member - London, United Kingdom
Fred Otsyeno
SICOT National Representative of Kenya - Nairobi, Kenya

WOC’s concern and involvement in surgical education and training is exercised at several levels, depending upon the local circumstances, local medical manpower and equipment. We suggest four categories:
  1. In the absence of all facilities, instruction might be given (with collaboration) to any to whom the patient, with an injury or musculoskeletal disease, has turned. This might, for example, be the Clinical Officers (in Malawi), nurses in the rural community, but more probably than any, the Traditional Healers. Where local politics allow, teaching and training to a level above 'First Aid' is offered, with emphasis on that which is safe and unlikely to make things worse! This will include splintage, mindful of the preservation of both the circulation and nerve function to distal parts of a limb. The standard of teaching would be equivalent to that appropriate to medical students.
    Post-basic orthopaedic training programme, with a well worked-out curriculum, can be offered to clinical officers (as happens in ENT and ophthalmology) to include physiotherapists, occupational therapists, plaster technicians and specialist orthopaedic nurses. 
  2. The second category is the young qualified doctors, who might be attracted to the possibility of pursuing a career in orthopaedics. For these the fundamentals of tissue repair, fracture reduction with splintage or traction, physical examination and musculoskeletal pathology are the building blocks of such a career. It must be born in mind that those who serve sub-Saharan Africa (and like places) have to be able to deal with numerically huge clinics. Therefore the technique of physical examination has to be streamlined to the essentials, often needing shortcuts. The most valuable and informative moment is when the patient walks towards the doctor’s desk and his mode of gait is clearly to be seen. This comes with experience; but can also be taught.
    The expansion of the undergraduate medical school curriculum means that less speciality orthopaedics is taught. Concise material addressing essential needs to be developed for different localities, with symposia on the conditions commonly to be faced in each country, always related to available facilities.
  3. The third level calls for 'hands-on' training for standard orthopaedic surgical procedures and their complications (avoidance and salvage). This will be set against the background of the biomechanics of structural skeletal replacement. This is the area in which bitter experience is gained and hard lessons learned. But its provision depends upon establishing safe sterile surgical techniques.
    There is also a place for highly specialised surgery (difficult by virtue of anatomical complexity, rather than hardware) to be tackled in host hospitals, particularly if groups of similar pathology can be collected together, and teams of visiting specialist surgeons can be organised. Opportunities for this training are quickly running out. Emphasis should be placed on the local set-up. Distant scholarships are rarely either available or relevant.
  4. The last and most important is special training for those selected as being proficient in the fundamentals to be sent to specialist centres where particular techniques are regularly in use on types of patient comparable with those seen in the trainee's home country. But it is equally important that attendance at these courses should be confined to those who would be able to make use of such special training in his or her home country. Otherwise, the training is a preparation for emigration. Plans must be appropriate to realistic prospects.
Each of these categories requires special tutors. Details of all courses must be made with and through those in charge of the home hospital's existing programme.

The first three categories call for visiting teachers to the place of limited resources, so that every part is relevant to the community and contributes to the local service. The fourth category calls for national organisation, at no great distance from the home hospital; for example the training centres in India, Egypt, and others designated and approved for the purpose. The ultimate aim is the development of Orthopaedics in the areas of the world with limited resources, to produce competent practical surgeons, not collectors of 'the curious'!

If these categories are accepted as the basis upon which training is to be organised, it should also be the basis upon which higher qualifications are to be judged. This comment has relevance to the curriculum and format of the various postgraduate examinations (the SICOT Diploma, COSECSA Fellowship, etc.).

With regard to the expense of setting up the above projects, the first three categories will call for financial support towards the cost of travelling to the relevant area. Local accommodation is not expensive and often free, at the invitation of a host institution. It has been suggested that in return for unpaid tuition, 50% of travelling expenses would be sufficient reward. Volunteer visits depend absolutely upon personal invitation, and therefore on local appreciation of the value of these visits. Once visits are formally arranged it is proposed that the College of Surgery (of each visitor) might be encouraged to 'sponsor', even perhaps to be involved in, the organisation. Careful audits of each programme will be kept for approval by those who support these plans.

The quality of the visitors may be an unknown to the host hospital at their first visit. It will therefore be the responsibility of the parent organisation to ensure that a volunteer knows exactly what is required and what is expected, and that two or more 'referee peers' are prepared to vouch for the visitor's expertise.