Verena Schreiber-Frank The 2017-2018 International Orthopaedic Trainee Survey AAOS Resident Assembly Andrew R. Jensen Musiliu Odunola Faseeh Shahab Nicholas Bonazza Christian Carrwik Verena Schreiber-Frank Kevin Cronin

Background The AAOS Resident Assembly surveyed orthopaedic trainees from across the globe to assess regional similarities and differences in international orthopaedic educational practices. An electronic questionnaire addressing seven domains related to orthopaedic education (see table) was sent to selected English-speaking senior trainees worldwide.

The survey was open for a period of six weeks. Survey Results The survey was open for a period of six weeks. 238 responses were received from trainees in 57 countries. These responses were grouped into nine geographic regions according to the CIA’s World Factbook: Africa Oceania Central America & the Caribbean Middle East North America East & Southeast Asia South America Europe South Asia

Survey Respondents by Region Region (N) Country (N) Africa (51) Cameroon (1) Central America & Caribbean (5) Costa Rica (1) Europe (36) Austria (2) Egypt (2) Dominican Republic (1) Belarus (1) Ethiopia (10) El Salvador (1) Belgium (1) Ghana (1) Haiti (2) Denmark (1) Kenya (7) Middle East (6) Iraq (1) France (2) Malawi (1) Qatar (1) Germany (5) Nigeria (20) Saudi Arabia (1) Iceland (1) Somalia (1) Syria (1) Italy (3) South Africa (1) Turkey (1) Latvia (2) South Sudan (1) Yemen (1) Luxembourg (1) Sudan (2) North America (38) Canada (1) Netherlands (1) Tanzania (3) Mexico (3) Poland (1) Tunisia (1) North America (34) Romania (5) East & Southeast Asia (12) Malaysia (1) Oceania (11) New Zealand (11) Serbia (1) Myanmar (Burma) (4) South Asia (73) Afghanistan (1) Span (2) Philippines (3) Bangladesh (3) Sweden (3) Singapore (1) India (53) United Kingdom (4) South Korea (1) Nepal (3) South America (6) Brazil (2) Taiwan (2) Pakistan (13) Chile (3) Colombia (1)

Residency Length - Findings In terms of the length of training, the average time spent in orthopaedic-specific training programs worldwide was 4.4 years. There was a large range in reported lengths according to geographic region, with trainees in Europe reporting the most years (5.4) and those in South America the least (3.2). The number of years spent in pre-orthopaedic training was highly variable due to differences in local educational systems.

Residency Length

The average number of work hours was 71 per week worldwide. Work Hours - Findings The average number of work hours was 71 per week worldwide. European trainees reported significantly fewer work hours (51 per week) than all other regions. Many training programs adhere to a 48 hour work week according to EU law (European Working Time Directive) 38% of respondents, mostly from Europe and North America, reported that work hour restrictions are in place. Trainees from most other regions reported no work hour restrictions.

Work Hours

Tests and Evaluations - Findings An end-of-residency certification process prior to become a practicing orthopaedic surgeon was common (88%) throughout all regions. The use of standardized case logs was also common (79%). 60% of respondents reported that they were not required to take an annual orthopaedic examination. The majority of respondents who did take an annual orthopaedic examination were from North America.

Educational Resources - Findings Textbooks were the most commonly used educational resource worldwide Particularly in Africa, East and Southeast Asia, and South Asia, where over 80% of trainees reported daily textbook use. The daily use of scientific journals was most common in North America (37%) and South America (50%). 61% of trainees in North America reported using the website Orthobullets (www.orthobullets.com) daily. Didactics were most commonly delivered on a weekly basis in all regions. Surgical simulators remain rare globally. Only 7% of trainees worldwide reported daily or weekly use.

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Educational Resources

Surgery Case Volume - Findings Trauma and fracture cases were the most commonly performed surgeries for trainees worldwide. More than 70% of respondents reported that they perform over 100 trauma/fracture cases during training. Tumor and spine cases were rare, with 42-43% of residents reporting that they perform fewer than 10 cases in each domain during training. 66% of North American trainees reported performing over 100 arthroscopy cases during training Compared to just 14% of trainees from all other regions.

Surgery Case Volume

Surgery Case Volume

Surgery Case Volume

Surgery Case Volume

Surgery Case Volume

Post-Residency Training - Findings Half of respondents stated that trainees in their country leave the country for fellowship. Only 6% of respondents stated that trainees don’t pursue fellowship in their country.

Summary There are more similarities than differences between international orthopaedic training programs: Long work hours and 4-5 years of specialty training. An emphasis on trauma and fracture cases. Heavy use of orthopaedic textbooks and scientific journals. The differences between training programs should be further investigated to determine optimal educational practices: What is the optimal number and distribution of cases for orthopaedic training? Should electronic educational resources be promoted? Are annual in-training examinations beneficial?

Thank you to the survey respondents Thank you to the survey respondents! Please visit the AAOS Resident Assembly website http://www.aaos.org/residentassembly