Orthopedic Residency in a Tertiary Care Hospital of India: Positives, Negatives and Perspectives for Change

Abstract

Background

Orthopaedic residency training is a 3-year period of preparation that converts a raw medical student into a proficient orthopaedic surgeon. Due to wide variations at different centers in India, the program in a tertiary hospital is presented, in an attempt to improve the overall levels of training.

Materials and Methods

PGIMER has produced many good surgeons who are well settled across the country and the world. A survey of the postgraduates of the last 30 years was done to highlight the perceptions about the program. An overview of the program was also added to the narrative to highlight the positive aspects of the training.

Results

132 Orthopaedic passed-out residents from PGIMER could be contacted. 97% of them rated their residency experience as excellent or good, and stated that they would recommend this program to new residents. Key points highlighted by them were the readiness of trainees for any surgical contingency after graduation, continuation of the mindset for research, and their prompt acceptability into their subsequent places of work due to their place of graduation.

Discussion

Converting an orthopaedic resident into a competent surgeon involves knowledge upgrades and impartation of skills; these are not limited to the theory of orthopaedics, but involve the thought processes and the planning as a surgeon, the attitude towards patient management, and a continuously inquisitive scientific mind. The shortcomings and strengths of the residency program in PGIMER are discussed; international standard methodology limited to this institute like formal log books, mentorship program, hands-on skill development through courses, etc. is something that is recommended to be mandatory in all residency programs.

Conclusion

The PGIMER Orthopaedic residency program could act as a basic model for other Indian medical schools, with any appropriate modifications. Standardization of Orthopaedic residency programs could allow upgrading to International levels.

Introduction

The Post-Graduate Institute of Medical Sciences and Research (PGIMER) is the 2nd highest rated medical school in India [1] and the Orthopedic residency program here is considered at par with the finest training programs in the country, if not in Asia. Orthopedic residency at PGIMER was started in 1964, with Prof. D S Grewal laying the foundation of learning and research, which was taken forward by multiple stalwarts of orthopedics. The subsequent Heads of Department have played a pivotal role in shaping the orthopedic know-how during the last 30 years in the country as well as abroad. Hundreds of orthopedic surgeons have passed out from this residency program and continue to serve the community in India and world-wide, with many currently in top notch academic and clinical positions. We intend to highlight what makes the orthopedic training different at PGIMER as compared to other medical colleges in India.

In PGIMER, there is a resident rotation system, which is so developed that the residents do not have to undergo the ordeal of long 24 h emergency duties, which is a regular part of the curriculum in other medical colleges. Also, in addition to significant exposure to the basics and advanced trauma principles and surgeries, the residents are exposed by rotation to various aspects of cold and elective orthopedics as well as scientific research and paper writing. This wholesome training plays a crucial role in the making of a competent orthopedic surgeon.

The current manuscript has attempted to review the orthopedic training in PGIMER, discussing the various aspects and layouts of the program; a survey was conducted from among those who have graduated from here to see their responses to the program as compared to places where they have subsequently worked. This survey and the experience of experience of some authors are used to give suggestions for an ideal orthopedic residency program for our country.

Evolution of Orthopedic Resident

Entry to PGIMER

A biannual entrance test is organized by PGIMER. Being an autonomous institute, the test is separate from the common NEET-PG entrance test, with a unique pattern of multiple correct options. The test for a long time was only held in the city of Chandigarh and was offline, but this was changed recently to allow young doctors from all over the country to give this exam. The different examination pattern ensures that students need to have a thorough knowledge of the subject, as reaching the right answer with the traditional exclusion method is difficult in PGIMER examinations. Based on marks, a ranking is given, and depending on the rank, branches are selected in the counseling. The trend in these counselling’s has seen a drastic change. From a point of time when Orthopedics was chosen in the top 5 ranks, it has gone down to be picked by people with ranks in 20′s and beyond. Saturation in our field, a hectic residency schedule, tough emergency duties and a strict discipline enforced in surgical fields are some of the reasons Orthopedics and other surgical fields have lost their charm to the young students.

Residency Structure

The residency program offered at PGIMER is a Masters of Orthopedic Surgery, spanned over 3 years like all other residency programs in India. It is divided into 6 semesters of 6 months each and 5–8 candidates are accepted into the program biannually; there are few institutes in India which have admissions twice a year that allows resident to be part of a 6 monthly staged training program. The program has various aspects but is not limited to surgical training and research only.

The Advanced Trauma Center (ATC) at PGIMER is a tertiary care trauma center which caters to a heavy load of trauma patients, averaging about 3000 patients annually. PGIMER has a wide catchment area, which spans the 5 major surrounding states including Uttar Pradesh, Haryana, Punjab, Himachal Pradesh and Jammu and Kashmir. The first four semesters/ two years of the residency are spent in rotation postings in the ATC emergency trauma department, wards, triage or the emergency operation theaters, where the residents manage these patients first hand under the guidance of a senior resident and consultants.

Surgical Training

First semester residents have a mandatory orientation program focused on the institute and the orthopedic department, the wards and the emergency and its basic functioning during the first 15 days of joining. Soon after these the new joining residents are posted in the trauma wards and are required to manage the patients there, accompanying a senior postgraduate for a month. Once they get a hang of the working and start to understand the basics, they start managing the wards by themselves, under the supervision and guidance of a Senior Resident (SR) and Consultants.

The newly joined resident is required to learn the basics of preoperative and post-operative management of patients. These include managing the patients and their associated co morbidities, wound management and surgical dressings, basic splint age techniques including slabs and casts, closed reduction maneuvers for simple fracture patterns, skin and skeletal tractions. All these activities are supervised by SRs who teach and mentor the Junior Resident (JR) in all these activities, further assisted by Consultants who are also designated mentors. The morning rounds are a daily routine in the trauma center; the Consultant in-charge along with the SR and all the JRs do a round of every ward and see how every patient is being managed. These rounds allow the residents to imbibe the trivial details related to bed side methods, communication with patients as well as all aspects of surgical planning.

Second and third semester residents are posted in emergency receiving room of trauma center. During this posting the orthopedic resident learns the basic skills of clinical examination, history taking, splintage and tractions, ordering and evaluation of X-rays, classification of fractures and decision making with respect to the operative plans for these fractures (as he assists the SR and Consultants in making these plans). The JR acquires practical first-hand knowledge of how, when and why to plan a specific surgery for a particular patient, and when not to operate. The resident is also obtains knowledge of orthopedic implants and when and why to use them. Questions like when to nail and when to plate are routinely asked on the rounds, forcing the JR to think and search for the answers. This semester lays the foundation for the surgical acumen of the trainee. Due to the heavy volume of patients, 3 operating tables run 24 h on all days. A team on each table comprises of a junior trainee (JR) (2nd or 3rd semester) and a senior trainee (JR) (4th or 6th semester) and a SR and the OT overall is led by a consultant. PGIMER gets a plethora of simple as well as complex trauma cases which are operated here. During these postings, the junior resident gets to observe a variety of cases which includes complex intra articular fractures, spine fractures, acetabulum fractures, hand and foot injuries, fracture of long bones and open fractures. Since most of the open fractures require soft tissue cover, the orthopedic residents work in close coordination with plastic surgery SRs and get to observe and even assist on wound covering procedures. There are several instances where the orthopedic surgical teams have to work in tandem with general surgeons, vascular surgeons and neurosurgeons in polytrauma. Cases of vascular injury (needing revascularization) are always accorded top priority both in the emergency room as well as in the operation theater. Thus, the trainee understands how timely intervention and availability of resources can prove to be limb saving in such cases. The trainee also gets to assist on basic surgeries and gets his first hands on experience in applying external fixators and limb amputations. Once he is proficient, which is judged by his seniors on the basis of soft tissue management, knowledge, reading and understanding of basic anatomy, and timely completion of surgery of elementary surgeries, he gets the oppurtunity to assist in other surgeries with increasing level of complexity.

The Fourth semester is when the resident is considered knowledgeable about the basics of orthopedic planning, management and surgical procedures. These six months are spent in the operation theater as a senior trainee. Several orthopedic surgeries like tibia nailing, forearm plating, femur nailing are done independently under supervision, only after he is able to reiterate the anatomy, fracture classification, plan as well as steps of surgery to the SR. The resident trainee assists the senior surgeons in cases involving complex intraarticular fractures, spinal injuries and acetabulum fractures. As the junior resident gets to spend maximum time operating on trauma cases during this semester, he is also known as a TRAUMA CAPTAIN, managing and ensuring timely induction and completion and acting as a link between the junior trainee and the SR. This is the time when the trainee develops his surgical skills and prowess as an orthopedic surgeon and is perhaps the most significant aspect of any resident’s training. Working in a high-volume center like PGIMER is an added bonus as the resident gets to observe and operate on a wide variety of cases which directly contributes to his surgical expertise.

The residents, in their fifth and sixth semester are posted in elective wards and get a significant exposure to elective orthopedics. They are posted in one of the units of the department, see patients in the outpatient clinics, assist the senior consultants in the operation theater and manage the patients and the wards. The residents are rotated between units during these two semesters. This ensures that the trainee gets the advantage of various consultants with their specialized expertise. This period is devoted to mainly observing and assisting arthroplasties, arthroscopic procedures, Illizarov fixations and other surgeries for deformity corrections, tumor excisions etc. Rotational postings during the fifth semester include rotation into the pediatric orthopedics unit in the Advanced Pediatric Center of PGIMER, learning the management of clubfoot deformity, pediatric deformities. Here the resident is also exposed to special clinics like cerebral palsy OPD, CTEV OPD. Surgeries for DDH, brachial plexus palsy, scoliosis, genu varum, cubitus Varus and so on are done routinely and the resident is an active assistant and is supposed to read about the cases posted.

The residents get adequate exposure to basic as well as advanced spine surgeries, as our department has a dedicated spine team. A special week for advanced spine surgery is organized twice every year by—BASS—British Association of Spine Surgeons and PGIMER where surgeons fly in from UK to operate along with the surgeons at PGIMER. JR’s get to present cases and learn the nuances of orthopedic examination and diagnosis from these international faculties.

A special focus is made on postoperative physiotherapy and rehabilitation protocols as there is an active physiotherapy department with the state-of-the-art machinery, where the JRs have a mandatory posting.

Academics

The great mix of surgical training and academics makes this residency program truly unique. The teaching methods in residency here are a mix of the old classical ways and modern methodology and aids. Trauma case discussions are conducted every morning where all operating teams and teams posted in emergency discuss the radiology of every case that has presented to the emergency and all the cases operated on the previous day in the Operation theaters. Plans are made for fresh cases and radiology of all operated cases is scrutinized thoroughly. The residents are taught how the case could have been managed in various other ways or how to avoid the errors made in fracture fixation. Discussion and teaching for the young residents go on hand in hand in these classes. Bedside teaching is done on rounds daily and issues relating to the patients are discussed. Case discussions are conducted every alternate day where tips and tricks of history taking, clinical examination, radiological investigations and management are discussed.

Journal clubs are conducted every week on Wednesday afternoons where articles relevant to our clinical setting from high impact journals of international repute are presented by SRs and discussed with inputs from all consultants. This has proved to be a great way to stay updated about the recent trends in orthopedics. This has also become a breeding ground for multiple letters to editor after these articles are scrutinized by multiple senior consultants. Seminars are conducted every week on Thursday afternoons and presented by Junior Residents under the guidance of consultants on various topics to teach important topics in easy and concise way. Conferences, workshops, CMEs are organized frequently at PGIMER and residents are encouraged to participate, present their research and attend these.

The mentorship program of our department is a unique one. Residents are allotted to a mentor at the beginning of the course. Every consultant has to mentor 3 junior residents, and this team is monitored by a senior faculty. The mentor guides his residents about studies, work life balance, professional nuances and keeps a check on their development through the logbook, which the resident updates with the procedures and surgeries he has seen or assisted. They form a WhatsApp group and chat at least twice a week which makes the residency program smooth and effective for a resident.

Another concept of international standards is the logbook. Residents are provided with an electronic log book at the beginning of the course where they record every procedure they see or assist or do from the day of joining to the completion of the course. Logbooks are reviewed by the mentor and senior faculty every month. All procedures done ranging from splints and tractions, surgeries assisted and performed independently, seminars and journal clubs attended, conferences attended, presentations and publications along with the sister specialties (plastics, anatomy and physiotherapy) postings are documented. This logbook reflects the overall performance of a resident and will be useful for future prospects.

One point of note is that all sixth semester junior residents have to attend an AO basic course, which enhances their hands-on skills. Similar Hands on procedures in spine and arthroscopy are being developed.

Research

PGIMER is an institute devoted to medical research and the Department of Orthopedics has lived up to its name as one of the top research departments in the country. The residents are encouraged to participate in research activities of the department. The thesis topics are decided, and the protocols are submitted at the end of 2nd semester. The residents are also encouraged to utilize this time and do a pilot study in the topic of their interest and later scale it up as their thesis. The trainees are given full freedom to choose topics which interest them, and consultants are allotted as thesis guides to help them in this regard. A lot of original research has been carried out by residents as part of their thesis in the past years. The research time allowed for the thesis in one and a half year and is submitted at the end of 5th semester. Besides the mandatory thesis research work, the residents are also encouraged to join the ongoing research projects of the department, write case reports and review articles. Almost all residents are included in one or another research work with one of the consultants. The department provides a conducive environment for the researcher and critical thinking is encouraged. All JRs are supposed to attend a course on Biostatistics, where they are supposed to undergo an exam based on research methodology and biostatistics, this adds to their skills and allows them to run statistics on their thesis data. The thesis conversion rate into an indexed publication is almost 100% in our department.

Residency Outcome

By the end of the 3-year residency program, the young surgeon is well versed with basic as well as advanced orthopedic procedures and develops a keen interest in the subject. He walks out as a confident doctor who, if needed, can perform any basic orthopedic surgery in the real world. He has an apt knowledge of patient management, preoperative, operative and postoperative care. He is academically well read, knows basic as well as complex orthopedic surgeries and has a background in research and is well versed with its methodologies. To evaluate if the above statement is correct, and to get appropriate feedback, a survey of past postgraduates was carried out.

Survey and Results

In an attempt to objectively get a feedback about the orthopedic residency program in PGIMER, we conducted a survey using a google form (https://docs.google.com/forms/d/e/1FAIpQLSdMNTv81BGOemlQUep2qfebAkinlLflSvQFe0TIVRPUU32dnw/viewform?usp=sf_link) with a specific questionnaire. This form was forwarded to all the PGIMER alumni who had passed out from the last 30 years, and who could be contacted; the form was filled on voluntary basis.

Over a span of 24 h we received 132 responses to our questionnaire. A few forms had been forwarded to other alumni who had passed out prior to 1990 also, and their responses were included. We were also informed that such a survey had made a few of the senior PGIMER alumni nostalgic and reminded them of their residency days.

40.9% of the participants in the survey were recent pass outs (postgraduates who had passed out 2014 to 2019). The second highest participants were the ones who had post graduated more than 15 years ago (31.1%). The current job description of the respondents were senior registrars (26.5%) followed by 26% as consultants in government institutes, 22% as consultants in private institutes, 13.6% as independent private practitioners and 11.5% respondents were settled in consultant positions abroad.

Responding to question 3, a direct question about their alma mater, 91.7% said that they would not want to do their post-graduation from any other college except PGIMER. 59.1% rated the residency program as excellent and 37.9% rated it to be good. 3%, on the other hand, found the residency program as non-satisfactory (some Ortho surgeons have converted into other specialties, like Income tax, Internist etc.; 5 out of 132).

On being asked if they were confident to operate independently right after post-graduation, 90.9% gave a thumbs up. 81.1% also agreed to being able to conceptualize or successfully publish research articles after they had passed out.

Since so many of the alumni had shifted institutes and places of work, we asked them if their orthopedic training was acknowledged as good at their new place of work. 94.7% gave a positive answer to it. 80% also felt they faced no difficulties in passing future exams like DNB, MRCS and so on. 91% of the participants, were still in contact with one or more of their senior consultants for professional and personal advice. A whopping 92% said they have counseled and would continue to counsel young medical students to take up residency in PGIMER.

Finally, 97% respondents were overall satisfied after completing their post graduate training from PGIMER. Those who felt need for improvement had passed out more than 15 years prior and were not aware of newer additions like super-specialties, fellowships, mentorships and strict logbook adherence which are currently being practiced in PGIMER since 2010.

Recommendations Based on PGIMER Protocol Regarding Orthopedic Residency Program

The main aim of any orthopedic residency program is to develop orthopedic surgeons who are competent, technically qualified, have a scientific approach, ability to communicate and are highly skilled instructor.

1. A standard protocol for training is essential for every post graduate program, which could be on the pattern as discussed earlier.

2. Hands-on cadaver and simulation workshops should be made more accessible to residents at least once in 6 months to improve their surgical acumen. e.g. arthroscopy, spine and AO type models.

3. A compulsory anatomy dissection posting should be mandatory for every junior resident.

4. A Basic statistics knowledge is essential, and every orthopaedic trainee should have passed a certified basic statistics examination (Like in PGIMER).

5. Every orthopaedic trainee in their residency program should be included in a team involving a senior resident and a faculty member for the entire duration of 3 years, so that academic progress of each individual can be closely monitored and problems can be addressed at the right time. (Something like the PGIMER mentorship program)

6. Maintenance of a logbook which should be checked and verified by the respective mentor assigned, is essential. The trainee should be assessed and graded at regular intervals, with respect to knowledge, clinical skills, operative skills, personality and ethics. Logbooks serve as a road map of the academic journey of an orthopaedic trainee.

7. Seminar presentations and journal club presentations should be made mandatory, once in 6 months, this not only helps the resident to acquire the best knowledge in a particular topic, but helps in improvement of one’s communication skills.

8. All trainees must attend conferences as much as possible and should be encouraged to give presentations at various conferences.

9. The status of orthopaedic residencies in all medical institutes should be monitored and assessed by the Medical Council of India (MCI) regularly to better comprehend the current discrepancies and their origin to develop new concepts.

10. Ensure training in ATLS for all residents during the 3 years, so that they can use the skills on real patients in emergencies.

11. 3 years of compulsory Senior Residency program should be enforced before an orthopaedic surgeon is allowed to practice independently as it would be the best time for a fresh orthopaedic surgeon to decide on the sub-speciality of his interest, which he would practice for his lifetime.

12. Further prospects like focussed subspecialties should be encouraged on the American model.

Discussion

The purpose behind writing this article was to highlight how the orthopedic residency program at PGIMER Chandigarh has been laid out and is considered at par, if not better to produce competent orthopedic surgeons.

Each country tailors the residency training program of its doctors to meet the challenges prevalent in that part of the world [2] (Fig. 1). In the Western world, particularly the United States, basic first aid and patient evacuation are considered the top priority in any trauma scenario [3]. This has been facilitated by a very well-developed emergency medical services or EMS system [4]. The population of the United States is relatively small as compared to India. This means a higher doctor to patient ratio and coupled with an effective insurance system, ensures that good treatment is available to everyone. The reduced patient load along with better equipped hospitals also means less burden of work on the trainee residents. This is in sharp contrast to the Indian scenario where a medical college in a metropolitan area handles close to 300–500 patients in the outpatient department and around 90–100 patients in the emergency room each working day [3]. In the case of PGIMER (which serves as a tertiary care center), the volume of trauma—both simple as well as neglected complex cases—is very high. This gives the junior resident in India a better exposure of a broader spectrum of orthopedic diseases. Moreover, in many cases, the residents have to rely more on their clinical acumen and less on sophisticated laboratory investigations. This allows them to rapidly develop the skills needed to perform a thorough and quick clinical examination which then guides them towards decision making. The same holds true as far as hands on training is considered.

Fig. 1.

Medical education pathway for a medical graduate who wants to pursue orthopedics in India

The vast load of trauma and emergency cases is also what sets PGIMER Chandigarh apart from its sister institute AIIMS, New Delhi. PGIMER has a “no refusal policy” for any patient presenting to the emergency department, regardless of bed availability and many cases are admitted on trolleys, thus over burdening the system. On the contrary, in other tertiary care centers, they have the authority to refuse admissions if the bed occupancy is full. This basic difference forces the resident to think outside the box, manage complex cases in compromised situations and also use facilities to the best of their ability.

Another important difference between the residency program in India and the United States is that Indian medical students and undergraduates are exposed to a wider variety of specialized areas towards the end of the MBBS curriculum [1]. This is because of the diversity of clinical problems present in India which require a doctor to have basic knowledge of all clinical specialties [3]. In the United States, on the other hand, the medical student applies for specialized training at the end of third year of medical school itself [2]. They rather spend more time (5 years) in their specialty training contrary to our 3-year residency programs. But the 5.5-year MBBS/under-graduation is the cornerstone of our healthcare system, which needs a large chunk of manpower and general doctors and less of specialists.

Even though some orthopedic diseases such as bone and joint infections, post-polio complications and skeletal tuberculosis are infrequently seen in the United States nowadays [2], orthopedic residency training in India emphasizes on these ailments along with a host of other commonly seen issues afflicting the country’s population such as clubfoot and neglected fractures.

The survey done gave us a lot of insights about how the residents who have passed out and are now settled in their lives as orthopedic surgeons over the past many years, look at the residency in retrospect. Our survey had a mixed representation from all age groups, thus portraying how a resident felt in the 1990s as well as in twenty-first century. Most of the participants were consultants in government or private institutions, a few had private practice, and a few had settled outside India. Only 9.6% of the participants wanted to pursue their residency from a different college, showing that residency at PGIMER is something almost everyone cherished. Also, a major chunk of the participants was confident to operate alone immediately upon post-graduation (91%). This number in itself speaks volumes about the kind of hands on and supervised training at PGIMER. 94% also agreed that their institute of residency was very well respected, and they were considered to be very well-trained orthopedic surgeons at their new places of work. This is a reflection among the orthopedic community that the residency at PGIMER provides a solid foundation for a budding orthopod. The best form of marketing is still word of mouth marketing, since 91% participants in the survey agreed that they would counsel their juniors to take orthopedic residency at PGIMER, this is an indirect thumbs up.

Two of the authors of this article have not done their residency from PGIMER but have been an integral part of orthopedics department in PGIMER since the past 10 years. Both the authors agree that the training, facilities, research acumen and academic exposure in PGIMER, makes for a very competent orthopedic residency program, with wholesome development and training of young orthopedic surgeons, further validating our findings.

It is a hope that this article helps in tailoring the residency program of orthopedics all over India.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.