ORTHOPAEDIC  

DEFINITION:In translation from its Greek root the term orthopedic means "straight child", reflecting the responsibility of the orthopedic surgeon to strive to maintain and restore proper function of the musculoskeletal system, not only in children but also in patients of all ages.

Having accomplished the general and specific objectives of orthopedic training, the graduate surgeon, upon completion of the educational program in Orthopedic Surgery, will be competent to function as a consultant in Orthopedic Surgery.

GENERAL OBJECTIVES:During the course of the residency, the resident must acquire a satisfactory knowledge of the principles common to all surgical practice. These principles include shock, resuscitation, post-operative care and complications, trauma to all parts of the body and the response to trauma, fluid, electrolyte and acid base disturbances, infections, neoplasia, bleeding, coagulation, thrombosis, surgical immunology, clinical pharmacology, genetics and epidemiology and biostatistics.

In addition, the resident must have clinical competence in, and detailed knowledge of the scientific rationale for the surgery of the entire musculoskeletal system. Experiences in those aspects of neurosurgery and plastic surgery that overlap orthopedic surgery are highly desirable. The resident must be at least familiar, and preferably have had exposure to spinal surgical techniques requiring transthoracic and transabdominal approaches. It is highly desirable that the resident has experience in, and knowledge of, basic prosthetics and orthotics and the medical aspects of rheumatic disease.

SPECIFIC OBJECTIVES:At the completion of training, the resident will have acquired the following competencies and will function effectively as:

Medical Expert/Clinical Decision-Maker

Orthopedic surgeons possess a defined body of knowledge and procedural skills, which are used to collect and interpret data, make appropriate clinical decisions, and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date, ethical, and cost-effective clinical practice. They display effective communication in partnership with patients, other health care providers, and the community. The role of medical expert/clinical decision-maker is central to the function of orthopedic surgeons, and draws on the competencies included in their other roles as communicator, collaborator, manager, health advocate, collaborator, scholar and professional.

The orthopedic resident must be able to relate basic science knowledge and principles to patient care. Furthermore, the orthopedic resident must be able to relate sound knowledge of axial and appendicular anatomy in an applied manner as a prelude to safe surgical exposure and appropriate manipulation of tissues.

General Requirements

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information and therapeutic options to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.
• Recognise personal limits of expertise.

Specific Requirements

Knowledge — Basic Science and Anatomy
Demonstrate knowledge of the following:

• the anatomy growth and development of the axial and appendicular skeleton; embryology, histology, physiology and biochemistry of bone, cartilage, tendon, ligament, muscle, nerve and skin
• fracture healing, wound healing, trauma management
• metabolic bone disease, congenital abnormalities, inflammatory conditions and arthritis, infections related to the musculoskeletal system
• pertinent biomechanical principles of the musculoskeletal system, including joint reconstruction
• pathology and treatment of soft tissue and bone neoplasia related to the musculoskeletal system
• pharmacology including principles of metabolism, action and toxicity of drugs commonly used in orthopedics, as well as variations associated with age, gender and ethnicity; be familiar with drug interactions and recognise and manage adverse drug reactions

Knowledge — Clinical
Recommend appropriate method in performing:

• medical history: relevant, concise, accurate and appropriate to the patient's problem(s)
• physical examination: relevant, sufficiently elaborate, and appropriate
• diagnostic tests: medically appropriate investigative tools in a cost-effective, ethical and useful manner
• medical imaging tests: appropriate imaging investigations; interpretation of basic x-ray, ultrasound, computer-assisted tomograph (CT), magnetic resonance imaging (MRI) and radionuclide studies
• clinical diagnosis and decision-making: analysis, synthesis and integration of all relevant data to formulate a rational and effective diagnostic and therapeutic strategy for problems encountered in patients of all ages
• documentation/presentation: well-documented and organised assessments and recommendations in written and/or coherent and concise verbal form in response to a request from another health provider
• preoperative planning: understand the concept; order of appropriate preoperative investigations to assist in planning; execution of preoperative plan during surgery
• intraoperative decision-making: arrive at correct, timely operative decisions for routine and complex procedures
• postoperative care: provide appropriate care to include effective pain management (with multidisciplinary assistance, if necessary), both in the hospital and office environments; recognise promptly and manage postoperative complications in an effective manner
• emergency management - recognition: able to identify and respond appropriately to urgent medical and surgical problems. Efficiently provide appropriate therapy
• emergency management - decision to operate: intervene based on rational interpretation of clinical and ancillary investigation. Intervention is timely, with appropriate preoperative assessment
• evidence-based practice: aware of the role of evidence in clinical decision-making. Able to access, retrieve and apply relevant information. Makes clinical judgments based on sound evidence

Knowledge — Technical

Demonstrate knowledge of surgical options that allow appropriate operative selection, including:

• trauma: management of fractures, joint and soft tissue injuries
• competence in all surgical and technical procedures commonly performed in orthopedics, including common congenital deformities (especially developmental dysplasia of the hip and clubfoot) as well as basic bone and soft tissue surgery
• use of surgical equipment: understand its use, recognize its limits and apply to tissues safely, simultaneously taking measures to protect both oneself and other associates from blood and airborne debris
• use of imaging equipment: understand its use, recognize the risks of, and appreciate safety measures required to protect patients, self and other personnel from ionizing radiation.

Communicator

Orthopedic surgeons will provide humane, high-quality care and establish effective relationships with patients, their families, other physicians, and other health professionals. Communication skills are essential for the functioning of an orthopedic surgeon, and are necessary for obtaining information from, and conveying information to patients and their families. Furthermore, these abilities are critical in eliciting patients' beliefs, concerns, and expectations about their illnesses, and for assessing key factors impacting on their patients' health.

General Requirements

• Establish therapeutic relationships with patients/families.
• Obtain and synthesise relevant history from patients/families/communities.
• Listen effectively.
• Discuss appropriate information with patients/families and the health care team.

Specific Requirements

• Recognize that being a good communicator is an essential function of a physician, and understand that effective patient-physician communication can foster patient satisfaction and compliance as well as influence the manifestations and outcome of a patient's illness and surgical intervention.
• Establish relationships with the patient that are characterized by understanding, trust, respect, empathy and confidentiality.
• Recognize the emotional stress for patients and families faced with orthopedic conditions and their associated surgical management, a stress especially accentuated in the treatment of children.
• Gather information not only about the disease but also about the patient's beliefs, concerns and expectations about the illness, while considering the influence of factors such as the patient's age, gender, ethnic, cultural and socioeconomic background, and spiritual values on that illness and on any proposed surgical intervention.
• Deliver information to the patient and family in a humane manner and in such a way that it is understandable; encourage discussion and promote patient's participation in decision-making to the degree that they wish.
• As a prelude to surgical intervention use above skills to obtain informed consent; appreciate alternative means of achieving consent if the patient is incompetent to provide consent, be it on the grounds of age or mental status, or other disqualifier.
• Understand and demonstrate the importance of cooperation and communication among health professionals involved in the care of individual patients such that the roles of these professionals are delineated and consistent messages are delivered to patients and their families.
• Maintain clear, accurate and appropriate written records.
• Write well-organized and legible orders and progress notes.
• Complete concise hospital discharge summaries promptly.
• Write well-organized letters, providing clear direction to the referring physician and other physician and allied personnel, where indicated.

Collaborator

Orthopedic surgeons work in partnership with others who are appropriately involved in the care of individuals or specific groups of patients. It is therefore essential for orthopedic surgeons to be able to collaborate effectively with patients and a multi-disciplinary team of expert health professionals for provision of optimal patient care, education, and research.

General Requirements

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

Specific Requirements

• Identify and describe the role, expertise and limitations of all members of an interdisciplinary team required to optimally achieve a goal related to patient care, a research problem, an educational task, or an administrative responsibility.
• Develop a care plan for a mutual-interest patient, that includes investigation, treatment and continuing care, whether preoperatively or postoperatively, as well as in both hospital and community settings.
• Participate in an interdisciplinary team, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing specialty-specific expertise.

Manager

Orthopedic surgeons function as managers when they make everyday practice decisions involving resources, co-workers, tasks, policies, and their personal lives. They do this in the settings of individual patient care, practice organizations, and in the broader context of the health care system. Thus, orthopedic surgeons require the abilities to prioritize and effectively execute tasks through teamwork with colleagues, and make systematic decisions when allocating finite health care resources. As managers, orthopedic surgeons are encouraged to take on positions of leadership within the context of professional organizations.

General Requirements

• Utilize resources effectively to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organisation.
• Utilize information technology to optimise patient care, life-long learning and other activities.

Specific Requirements

• Have basic knowledge of how to function effectively in health care organizations, ranging from an individual clinical practice to organizations at the local, regional and national level.
• Have basic knowledge of the structure, financing, and operation of the Canadian health system and its facilities; and function effectively within it.
• Have an ability to access and apply a broad base of information to the care of patients in ambulatory care, hospitals and other health care settings.
• Make clinical decisions and judgments based on sound evidence for the benefit of individual patients and the population served. This allows for an advocacy role primarily for the individual but in the context of societal needs when monitoring and allocating needed resources.
• Be open to working effectively as a member of a team or a partnership and to accomplish tasks whether one is a team leader or a team member.
• Have basic knowledge of population-based approaches to health care services and their implication for medical practice.

Health Advocate

Orthopedic surgeons recognize the importance of advocacy activities in responding to the challenges represented by those social, environmental, and biological factors that determine the health of patients and society. They recognize advocacy as an essential and fundamental component of health promotion that occurs at the level of the individual patient, the practice population, and the broader community. Health advocacy is appropriately expressed both by the individual and collective responses of orthopedic surgeons in influencing public health and policy.

General Requirements

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognise and respond to those issues where advocacy is appropriate.

Specific Requirements

Demonstrate knowledge of the following:

• Determinants of health by identifying the most important determinants of health (i.e., poverty, unemployment, early childhood education, social support systems), being familiar with the underlying research evidence, and applying this understanding to common problems and conditions in orthopedics.
• Public policy for health by describing how public policy is developed; identifying current policies that affect health, either positively or negatively (i.e., communicable diseases, tobacco, substance abuse); and citing examples of how policy was changed as a result of actions by physicians.

Demonstrate knowledge of these concepts as applied to the following three levels:

• In the management of individual patients, by identifying the patient's status with respect to one or more of the determinants of health (e.g., unemployment); adapting the assessment and management accordingly (e.g. the medical history to the patient's social circumstances); and assessing the patient's ability to access various services in the health and social system.
• In the analysis of an orthopedic surgeon's practice population work with the specialty society, and other associations, in identifying current "at risk" groups within a given orthopedic practice and applying the available knowledge about prevention to "at risk" groups within the practice; and contributing "group data" for better understanding of health problems within the population.
• In relation to the general population by describing, in broad terms, the key issues currently under debate regarding changes in the health care system, indicating how these changes might affect societal health outcomes and advocating to decrease the burden of illness (at a community or societal level) of a condition or problem relevant to orthopedics through a relevant orthopedic society, community-based advocacy group, other public education bodies, or private organizations.

Scholar

Orthopedic surgeons engage in a lifelong pursuit of mastery of their domain of professional expertise. They recognize the need to be continually learning and model this for others.

Through their scholarly activities, they contribute to the appraisal, collection, and understanding of health care knowledge, and facilitate the education of their students, patients, and others.

General Requirements

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, house staff/students and other health professionals.
• Contribute to development of new knowledge.

Specific Requirements

Demonstrate the following clinical skills:

• Pose a clinical question.
• Recognize and identify gaps in knowledge and expertise around the clinical question.
• Formulate a plan to fill the gap including to:
  1. conduct an appropriate literature search based on the clinical question;
  2. assimilate and appraise the literature;
  3. develop a system to store and retrieve relevant literature;
  4. consult others (physicians and other health professionals) in a collegial manner.
• Propose a solution to the clinical question.
• Implement the solution in practice. Evaluate the outcome and reassess the solution (re-enter the loop at a) or b).
• Identify practice areas for research.

Demonstrate the following research skills:

• Pose a research question (clinical, basic or population health).
• Develop a proposal to solve the research question including to:
  1. conduct an appropriate literature search based on the research question;
  2. identify, consult and collaborate with appropriate content experts to conduct the research; and to
  3. propose a methodological approach to solve the question.
• Carry out the research outlined in the proposal.
• Defend and disseminate the results of the research.
• Identify areas for further research that flow from the results.

Acquire the following educational experience:

• Demonstrate knowledge of, and the ability to apply, the principles of adult learning, with respect to oneself and others.
• Demonstrate knowledge of preferred learning methods in dealing with students, residents, and colleagues.

Professional

Orthopedic surgeons have a unique societal role as professionals with a distinct body of knowledge, skills, and attitudes dedicated to improving the health and well-being of others.

Orthopedic surgeons are committed to the highest standards of excellence in clinical care and ethical conduct, and to continually perfecting mastery of their discipline.

General Requirements

• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practise medicine ethically consistent with obligations of a physician.

Specific Requirements

Achieve the following discipline-based objectives:

• Display attitudes commonly accepted as essential to professionalism.
• Use appropriate strategies to maintain and advance professional competence.
• Continually evaluate his/her abilities, knowledge and skills and know his/her limitations of professional competence.

Achieve the following personal/professional boundary objectives:

• Adopt specific strategies to heighten personal and professional awareness and explore and resolve interpersonal difficulties in professional relationships.
• Consciously strive to balance personal and professional roles and responsibilities and to demonstrate ways of attempting to resolve conflicts and role strain.

Achieve the following objectives related to ethics and professional bodies:

• Know and understand the professional, legal and ethical codes to which physicians are bound.
• Recognize, analyze and attempt to resolve in clinical practice ethical issues such as truth-telling, consent, advanced directives, confidentiality, end-of-life care, conflict of interest, resource allocation, research ethics, etc.
• Have basic knowledge of and be able to apply relevant legislation that relates to the health care system in order to guide one's clinical practice.
• Recognize, analyze and know how to deal with unprofessional behaviors in clinical practice, taking into account local and provincial regulations. 

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in orthopedic surgery must be consistent with the specialty training requirements.

In addition to offering the components noted in the specialty training requirements all accredited programs in orthopedic surgery should offer community-based learning electives where possible.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in orthopedic surgery.

In those cases where a university has sufficient resources to provide most of the training in orthopedic surgery but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

The teaching faculty should possess sufficient knowledge of all recognized specialty groups within orthopedic surgery so that terminal objectives for the residents can be met. This must include, but is not restricted to, adult reconstructive surgery, upper and lower limb reconstructive surgery, spine surgery and pediatric orthopedics.

In addition, residents must have access to teaching faculty cognizant of the non-surgical management of diseases of the locomotor system including the sequelae of metabolic bone disease and the more common arthritic conditions.

In addition, it is desirable for the orthopedic teaching faculty to include individuals with the ability to teach and supervise residents in basic science, epidemiology and formal educational training.

2. Number and Variety of Patients

There must be an adequate number of patients to ensure wide experience of the resident to all common aspects of orthopedic care:

1. Adult Reconstruction

Surgery of the arthritic patient including joint replacement; internal derangement of joints; surgery of the foot and ankle; upper limb surgery including reconstruction of deformity and instability in the shoulder, elbow and wrist.

2. Pediatric

The management of congenital and acquired deformities in the child; the management of scoliosis and developmental dysplasias; exposure to childhood diseases with musculoskeletal sequelae.

3. Oncology

Oncology exposure to all benign and malignant conditions of the musculoskeletal system including secondary disease in all age groups.

4. Trauma

There must be an adequate number of patients to provide each resident with extensive training in the recognition and management of injuries to all parts of the musculoskeletal system as well as a broad exposure to severe injury in other body systems. Therefore the range of trauma and the number of patients must include fractures and dislocations, joint injuries, spinal fractures, pelvic fractures and fractures associated with vascular injury.

There also must be sufficient numbers of patients to allow the resident to participate in the initial management of multiple trauma as a member of the trauma team; furthermore, all residents must have access to sufficient numbers of patients being cared for in the intensive care unit following initial management of their injury.

5. Subspecialty Areas

Adequate numbers of patients must be available for residents to gain confidence in the assessment and management in the following areas:

1. Upper extremity
2. Spine
3. Foot & Ankle
4. Sports
2. Clinical Services Specific to Orthopedic Surgery
   1. In-Patients

One faculty member is clearly identified as the person responsible for the educational activities within the unit. The resident would report to that faculty individual or to a designate. The head of the unit is responsible for assessment of the resident including verbal reports of progress and an ITER to be completed at the end of each resident rotation.

There must be adequate operating room time and appropriate facilities to provide graded surgical responsibility for residents in the program.

2. Ambulatory Services

Ambulatory services may be divided into many categories.

                                                         i.            Outpatient clinics or offices in which residents act as orthopedic consultants are essential in order for the residents to experience outpatient office management of common musculoskeletal conditions.

                                                       ii.            Recognizing that lack of continuity of care frequently secondary to prolonged waiting lists for elective surgery clinics must be structured so that the resident may examine patients scheduled for elective reconstructive orthopedic surgery. These pre-operative assessment clinics should be structured in such a way that the resident has an opportunity to obtain a history, perform a physical examination and review appropriate laboratory investigations for patients for whom he or she may not be providing some part of their surgical care, but may use the experience to learn those skills appropriate to pre-operative assessment.

                                                      iii.            Clinic in which post-discharge follow-up is provided for patients is also necessary to enable the resident to become familiar with the post-operative management of musculoskeletal patients including routine post-operative management of reconstructive procedures, fracture care, and the management of complications of both elective and emergency surgery.

                                                     iv.            Clinics to provide concentrated experience in special areas of orthopedic surgery are also an important aspect of resident education.

3. Community Learning Experiences

Community orthopedic surgery may differ in scope and delivery from orthopedic surgery taught in university centres.Community experiences offered to orthopedic surgery residents must provide a learning environment with appropriate supervision, patient encounters, and opportunities for evaluation based on rotation specific objectives. This assumes administrative support and linkages with the university.

4. Intensive Care

Units organized for teaching are required to provide experience in the broad field of supportive care of critically ill and injured patients. The organization of the Intensive Care Unit must be directed in part toward the management of trauma patients. Orthopedic residents rotating in these units must assume major responsibilities under appropriate supervision for management of these trauma patients. Rotation specific objectives for orthopedic residents in Intensive Care Units must be available for all Intensive Care Unit rotations.

5. Emergency Facilities

Emergency facilities are not necessary in all hospitals in which the residents have rotations. However, in those hospitals in which Emergency Departments are available the resident must be responsible in a graded fashion for consultations to the Emergency Department. In addition, it is anticipated that orthopedic residents will participate in the management of all multiple injured patients seen in the Emergency Department; furthermore he or she will be responsible for the initial consultation and management of all patients with displaced fractures or dislocations.

In those residency programs in which orthopedic residents have a defined rotation in emergency medicine, rotation specific objectives for that rotation must be available to the orthopedic program director.

4. Supporting Services — Clinical, Diagnostic, Technical

There should be resources to provide residents with experience in amputation surgery and rehabilitation. A spinal injury facility is also highly desirable particularly dealing with the many aspects of spinal cord injury.

Experience relevant to orthopedic surgery should be available through appropriate rotations or other arrangements through the core surgery program.

Associated medical services particularly rheumatology, infectious disease and anesthesia should be readily available to the resident for indepth education regarding understanding the methods and concepts of medical rheumatology, musculoskeletal infections and the rudiments of general and local anesthesia.

It is important that the resident be exposed during training to orthopedic pathological material with organized teaching for residents in orthopedics and to diagnostic radiology with facilities for instruction in the performance and interpretation of studies appropriate to orthopedic surgery.

Orthopedic training must be carried out in facilities which offer the optimum quality of patient care and the optimum quality of educational experience for the resident. There must be adequate access to library resources in all clinical teaching units. In addition, the standard educational materials including modern textbooks and current recognized journals, the residency program at one or more sites should try to offer resident exposure to educational technology such as interactive learning programs and computer simulation.

In addition, physical resources which are desirable but not necessary include facilities in which to provide instruction on prosthetics and orthotics in the clinic setting, bio-engineering and some aspects of rehabilitation.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

There must be a program of organized scholarly activities such as journal clubs, rounds, seminars and research conferences. Service demands must not seriously interfere with the ability of the residents to follow the academic program. Organized scholarly activities should include dedicated educational time for residents. It is preferable that this time be allocated as part of the standard working day of the resident and not be scheduled prior to or following the standard working day.

Teaching must be adequate in the advanced clinical knowledge essential to the understanding of the practice of orthopedic surgery in those areas outlined in the preceding sections.

The program may include didactic lectures and seminars, teaching rounds, special conferences, resident assignments or laboratory work, technical demonstrations or journal clubs.

This teaching in both basic science and clinical orthopedics must be carried out in addition to the direct resident experience with patients.

This program may be provided on an integrated basis with the university educational program and with other institutions. It may be multidisciplinary.

2. Basic and Clinical Sciences Relevant to Orthopedic Surgery

A coordinated educational program must be provided in orthopedic surgery and associated fields. This should include definitive teaching in basic sciences, in particular the relevant aspects of anatomy, biomechanics, microbiology, pharmacology and pathology.

3. Biomedical Ethics

The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to orthopedic surgery.

4. Communication Skills

There must be opportunities for residents to learn effective communication skills for interacting with their patients and their families, colleagues and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

6. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.All institutions participating in the education program must show evidence of an active quality assurance/improvement program. Appropriate involvement of resident staff in these programs is highly desirable.

7. Research Opportunities for Residents

All programs must offer suitable opportunities for resident research including appropriate faculty supervision and an appropriate venue for presentation of such research.

There should adequate facilities for clinical investigation and close association between the residents, active investigators and the staff.

8. Faculty Research

A program to promote and encourage research among the faculty is highly desirable and evidence of such a program should be found in a listing of faculty publications and presentations.

9. Outside Conferences

The program should provide opportunities for residents to attend conferences outside their own university.

SPECIALTY REQUIREMENTS:

Approved residency training including:

1.      Core training in surgery.

2.     Approved residency training in orthopedic surgery.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Master of Surgery(M.S):

Thirty six months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.