Improvement of Orthopedic Residency Programs and Diversity: Dilemmas and Challenges, an International Perspective

Document Type : PERSPECTIVE


1 Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

2 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

3 Universitaets Spital Zuerich, Switzerland

4 University of Tehran, Tehran, Iran

5 Michigan Musculoskeletal Institute, Madison Heights, USA

6 Department of Trauma, Klinikum Dortmund, Germany

7 Department of Trauma, Johannes Wesling Klinikum Minden, Germany

8 Department of Orthopedics, University of Texas, USA

9 Joint Reconstruction Research Center Tehran University of Medical Sciences

10 Fortis Bone and Joint Institute, India

11 Department of Orthopedics, St Vinzenz Hospital Dinslaken, Germany

12 Omsk State Medical University, Russia

13 R.R. Vreden Russian Research Institute of Traumatology and Orthopaedics. Saint Petersburg, Russia

14 Department of Orthopaedic Surgery, School of Medicine University of Zagreb,Croatia


Background: To date, little has been published comparing the structure and requirements of orthopedic training programs
across multiple countries. The goal of this study was to summarize and compare the characteristics of orthopedic training
programs in the U.S.A., U.K., Canada, Australia, Germany, India, China, Saudi Arabia, Russia and Iran.
Methods: We communicated with responders using a predetermined questionnaire regarding the national orthopedic
training program requirements in each respondent’s home country. Specific items of interest included the following: the
structure of the residency program, the time required to become an orthopedic surgeon, whether there is a log book,
whether there is a final examination prior to becoming an orthopedic surgeon, the type and extent of faculty supervision,
and the nature of national in-training written exams and assessment methods. Questionnaire data were augmented by
reviewing each country’s publicly accessible residency training documents that are available on the web and visiting
the official website of the main orthopedic association of each country.
Results: The syllabi consist of three elements: applied clinical knowledge, applied clinical skills, and professional and
management skills. The application of simulation techniques for both teaching and assessment are fundamental to
modern surgical education. The skill of today’s trainees predicts the quality of future orthopedic surgeons. The European
Board of Orthopaedics and Traumatology (EBOT) exam throughout the European Union countries should function as
the European board examination in orthopedics. We must standardize many educational procedures worldwide in the
same way we standardized patient safety.
Conclusion: Considering the world’s cultural and political diversity, the world is nearly unified in regards to orthopedics.
The procedures (structure of the residency programs, duration of the residency programs, selection procedures, using a log
book, continuous assessment and final examination) must be standardized worldwide, as implemented for patient safety.
To achieve this goal, we must access and evaluate more information on the residency programs in different countries and
their needs by questioning them regarding what they need and what we can do for them to make a difference.
Level of evidence: III


Main Subjects

1. Mäkinen TJ, Madanat R, Kallio P, Mineiro J, Kiviranta I.
The current state of the fellowship examination of the
European Board of Orthopaedics and Traumatology.
Eur Orthop Traumatol. 2014; 5(3):217-20.
2. Madanat R, Mäkinen TJ, Ryan D, Huri G, Paschos N,
Vide J. The current state of orthopaedic residency in
18 European countries. Int Orthop. 2017; 41(4):681-7.
3. Pour AE, Bradbury TL, Horst P, Harrast JJ, Erens GA,
Roberson JR. Trends in primary and revision knee
arthroplasty among orthopaedic surgeons who take
the American Board of Orthopaedics part II exam. Int
Orthop. 2016; 40(10):2061-7.
4. O’Connor MI. Medical school experiences shape
women students’ interest in orthopaedic surgery. Clin
Orthop Relat Res. 2016; 474(9):1967-72.
5. Syed S, Mirza AH, Ali A. A brief comparison of
orthopaedic training in English-speaking countries.
Ann R Coll Surg Engl. 2009; 91(3):226-31.
6. Inaparthy PK, Sayana MK, Maffulli N. Evolving trauma
and orthopedics training in the UK. J Surg Educ. 2013;
7. Putineanu DC. Aotrauma course-basic principles of
fracture management. Inaotrauma course. Texas:
Basic Principles of Fracture Management; 2017.
8. Brown GA, Firoozbakhsh K, DeCoster TA, Reyna JR,
Moneim M. Rapid prototyping: the future of trauma
surgery? J Bone Joint Surg Am. 2003; 85-A(Suppl
9. Skakun EN, Wilson DR, Taylor WC, Langley GR. A
preliminary examination of the in-training evaluation
report. J Med Educ. 1975; 50(8):817-9.
10. Weigelt JA, Brasel KJ, Bragg D, Simpson D. The
360-degree evaluation: increased work with little
return? Curr Surg. 2004; 61(6):616-26.
11. Shah J, Darzi A. Surgical skills assessment: an ongoing
debate. BJU Int. 2001; 88(7):655-60.
12. Regehr G, Eva K, Ginsburg S, Halwani Y, Sidhu R. 13
Assessment in postgraduate medical education.
Canada: Trends and Issues in Assessment in the
Workplace; 2011.
13. Pitts D, Rowley DI, Sher JL. Assessment of performance
in orthopaedic training. J Bone Joint Surg Br. 2005;
14. Mankin HJ. The orthopaedic in-training examination
(OITE). Clin Orthop Relat Res. 1971; 75(1):108-16.
15. Lackey WG, Jeray KJ, Tanner S. Analysis of the
musculoskeletal trauma section of the orthopaedic intraining
examination (OITE). J Orthop Traum. 2011;
16. Seybold JD, Srinivasan RC, Goulet JA, Dougherty PJ.
Analysis of the orthopedic in- training examination
(OITE) musculoskeletal trauma questions. J Surg
Educ. 2012; 69(1):8-12.
17. Training standards committee of the British
orthopaedic association. Available at: URL: https://
Go99xZMbFwM8F8NPmasLM; 2007.
18. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W.
Testing technical skill via an innovative “bench station”
examination. Am J Surg. 1997; 173(3):226-30.
19. Hammond J. Simulation in critical care and trauma
education and training. Curr Opin Crit Care. 2004;
20. Hamilton N, Freeman BD, Woodhouse J, Ridley C,
Murray D, Klingensmith ME. Team behavior during
trauma resuscitation: a simulation-based performance
assessment. J Grad Med Educ. 2009; 1(2):253-9.
21. Neue Weiterbildungsordnung für Chirurgie. Available
at: URL:
22. Krankenhausskandal. Ärzte und Krankenschwestern
bekennen sich zu Behandlungsfehlern Available at:
video282930.html; 2013.
23. Flierl MA. German surgical residency training - quo
vadis? Patient Saf Surg. 2008; 25(2):9.
24. Ansorg J, Hassan I, Fendrich V, Polonius MJ, Rothmund
M, Langer P. Quality of surgical continuing education
in Germany. Dtsch Med Wochenschr. 2005;
25. Johnson AL, Sharma J, Chinchilli VM, Emery SE,
McCollister Evarts C, Floyd MW, et al. Why do medical
students choose orthopaedics as a career? J Bone
Joint Surg Am. 2012; 94(11):e78.
26. Perl M, Stange R, Niethard M, Münzberg M. Further
training in the faculty of orthopedics and trauma
surgery. Outstanding, average or insufficient.
Unfallchirurg. 2013; 116(1):10-4.
27. Martin KD, Belmont PJ, Schoenfeld AJ, Todd M,
Cameron KL, Owens BD. Arthroscopic basic task
performance in shoulder simulator model correlates
with similar task performance in cadavers. J Bone
Joint Surg Am. 2011; 93(21):1271-5.
28. Al-Ahaideb A, Alrabai HM, Alrehaili OA, Al-Khawashki
HM, Awwad W, Algarni AD. The Saudi Orthopedic
Residency Program: a comparison of the Riyadh
training center with other Saudi training centers. J
Taibah Univ Med Sci. 2015; 10(1):116-21.
29. Al-Ahaideb A, Alrabai HM, Alrehaili OA, Aljurayyan
AN, Alsaif RM, Algarni N, et al. Evaluation of the
orthopedic residency training program in Saudi
Arabia and comparison with a selected Canadian
residency program. Adv Med Educ Pract. 2014;
30. Salazar D, Schiff A, Mitchell E, Hopkinson W. Variability
in accreditation council for graduate medical
education resident case log system practices among 
orthopaedic surgery residents. J Bone Joint Surg Am.
2014; 96(3):e22.
31. Nantulya VM, Reich MR. The neglected epidemic: road
traffic injuries in developing countries. BMJ. 2002;
32. Lavy CB, Mkandawire N, Harrison WJ. Orthopaedic
training in developing countries. Bone Joint Surg Br.
2005; 87(1):10-1.
33. Arora A, Agarwal A, Gikas P, Mehra A. Musculoskeletal
training for orthopaedists and nonorthopaedists:
experiences in India. Clin Orthop Relat Res. 2008;
34. PG curriculum. Delhi: University of New Delhi; 2014.
35. Jain AK. Orthopedic services and training at a
crossroads in developing countries. Indian J Orthop.
2007; 41(3):177-9.
36. Jain AK. Teaching-learning: an integral component of
sound patient care. Indian J Orthop. 2008; 42(3):239-40.
37. Kumar S, Tuli SM. Orthopedic education: Indian
perspective. Indian J Orthop. 2008; 42(3):245-6.
38. Menon J, Patro DK. Undergraduate orthopedic
education: is it adequate? Indian J Orthop. 2009;
39. Natarajan MV. Orthopedic training in India: Time to
change. Indian J Orthop. 2012; 46(3):257-8.
40. Colleges and courses search. Medical Council of India.
Available at: URL:
InformationDesk/CollegesCoursesSearch; 2017.
41. Leung KS, Ngai WK, Tian W. Orthopaedic training in
China: experiences from the promotion of orthopaedic
specialist training in China. J Bone Joint Surg Br. 2011;
42. Ortho-online, China. Available at: URL: http://www.; 2007.
43. National Health and Family Planning Commission.
National health and family planning commission of
science and technology and education. Beijing:
National Health and Family Planning Commission;
44. People’s Republic of China National Health and Family
Planning Commission. National health and family
planning commission of science and technology and
education. Beijing: National Health and Family
Planning Commission; 2014.
45. National Health and Family Planning Commission.
National health and family planning commission of
science and technology and education. Beijing:
National Health and Family Planning Commission;
46. Akl EA, Mustafa R, Bdair F, Schunemann HJ. The United
States physician workforce and international medical
graduates: trends and characteristics. J Gen Intern
Med. 2007; 22(2):264-8.
47. Dimick J, Ruhter J, Sarrazin MV, Birkmeyer JD. Black
patients more likely than whites to undergo surgery
at low-quality hospitals in segregated regions. Health
Aff (Millwood). 2013; 32(6):1046-53.
48. Kelaher MA, Ferdinand AS, Paradies Y. Experiencing
racism in health care: the mental health impacts for
Victorian Aboriginal communities. Med J Aust. 2014;
49. Johnson RL, Roter D, Powe NR, Cooper LA. Patient
race/ethnicity and quality of patient-physician
communication during medical visits. Am J Public
Health. 2004; 94(12):2084-90.
50. Centers for Disease Control and Prevention. US public
health service syphilis study at Tuskegee. New York:
Centers for Disease Control and Prevention; 2013.
51. Fact sheet on the 1946-1948 US public health service
sexually transmitted diseases (STD) inoculation study.
New York: US Department of Health and Human
Services; 1948.
52. Jones A, Kwoh CK, Kelley ME, Ibrahim SA. Racial
disparity in knee arthroplasty utilization in the
veterans health administration. Arthritis Rheum.
2005; 53(6):979-81.
53. Skinner J, Weinstein JN, Sporer SM, Wennberg JE.
Racial, ethnic, and geographic disparities in rates of
knee arthroplasty among Medicare patients. N Engl J
Med. 2003; 349(14):1350-9.
54. Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W,
Rimm AA. Race and sex differences in mortality
following fracture of the hip. Am J Public Health. 1992;
55. Paxton EW, Inacio MC, Singh JA, Love R, Bini SA,
Namba RS. Are there modifiable risk factors for
hospital readmission after total hip arthroplasty in a
US Healthcare System? Clin Orthop Relat Res. 2015;
56. Adelani MA, O’Connor MI. Perspectives of orthopedic
surgeons on racial/ethnic disparities in care. J Racial
Ethn Health Disparities. 2017; 4(4):758-62.
57. Christie DJ, Dawes A. Tolerance and solidarity. J Peace
Psych. 2001; 7(2):131-42.
58. Singh K, Sivasubramaniam P, Ghuman S, Mir HR. The
dilemma of the racist patient. Am J Orthop (Belle
Mead NJ). 2015; 44(12):E477-9.
59. Manring MM, Calhoun JH. Biographical sketch: Ruth
Jackson, MD, FACS 1902-1994. Clin Orthop Relat Res.
2010; 468(7):1736-8.
60. Title IX, Education Amendments of 1972. U.S.
Department of Labor. Available at: URL: https://www.; 1972.
61. Rohde RS, Wolf JM, Adams JE. Where are the women
in orthopaedic surgery? Clin Orthop Relat Res. 2016;
62. Lattanza LL, Meszaros-Dearolf L, O’Connor MI, Ladd
A, Bucha A, Trauth-Nare, et al. The Perry initiative’s
medical student outreach program recruits women
into orthopaedic residency. Clin Orthop Relat Res.
2016; 474(9):1926-6.
63. Van Heest AE, Agel J. The uneven distribution of
women in orthopaedic surgery resident training
programs in the United States. J Bone Joint Surg Am.
2012; 94(2):e9.
64. White AA. Justification and needs for diversity in
orthopaedics. Clin Orthop Relat Res. 1999; 362(1):
65. Gerechter Frieden statt, vernetzte Sicherheit–Zivile
Krisenprävention, Gewaltverzicht und konstruktive
Konfliktbearbeitung als Maximen derdeutschen
Außenpolitik. Available at: URL: http://www.
AKUF-Pressemitteilung-01.pdf; 2011.
66. Willy C, Hauer T, Huschitt N, Palm HG. Einsatzchirurgie”-
-experiences of German military surgeons in
Afghanistan. Langenbecks Arch Surg. 2011; 396(4):
67. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez
MH, Sewankambo NK, et al. Towards a common
definition of global health. Lancet. 2009; 373(9679):
68. Farmer PE, Kim JY. Surgery and global health: a view
from beyond the OR. World J Surg. 2008; 32(4):533-6.
69. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In:
Jamison DT, Breman JG, Measham AR, Alleyne G,
Claeson M, Evans DB, Jha P, et al, editors. Disease
control priorities in developing countries. 2nd ed.
Oxford: Oxford University Press; 2006. P. 1245-60.
70. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray
CJ. Global burden of disease and risk factors. New
York: The World Bank and Oxford University Press;
71. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K,
Aboyans V, et al. Global and regional mortality from
235 causes of death for 20 age groups in 1990 and
2010: a systematic analysis for the Global Burden of
Disease Study 2010. Lancet. 2012; 380(9859):2095-
72. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM,
Bose K, et al. Global patterns of mortality in young
people: a systematic analysis of population health
data. Lancet. 2009; 374(9693):881-92.
73. Kotagal M, Agarwal-Harding KJ, Mock C, Quansah R,
Arreola-Risa C, Meara JG. Health and economic
benefits of improved injury prevention and trauma
care worldwide. PLoS One. 2014; 9(3):e91862.
74. Wolf BR, Britton CL. How orthopaedic residents
perceive educational resources. Iowa Orthop J. 2013;
75. Agarwal-Harding KJ, von Keudell A, Zirkle LG, Meara
JG, Dyer GS. Understanding and addressing the global
need for orthopaedic trauma care. J Bone Joint Surg
Am. 2016; 98(21):1844-53.
76. Fleischman AN, Rothman RH. Important lessons
learned from nearly a half-century of orthopaedic
practice. Arch Bone Jt Surg. 2017; 5(4):206-7.