O Canada! Country of the Great Lakes and the Rockies, with coasts
reaching two oceans, a great mix of English and French cultures,
embraced diversity, and a healthy economy, Canada can boast of being
one of the best places in the world to live in the twenty-first
century.
In 1945, Dr. J.E. Samson, a well-known orthopaedist from Montréal,
along with other colleagues across the country, founded the Canadian
Orthopaedic Association. Before that, most Canadians who wished
to become orthopaedic surgeons were obligated to travel to England,
continental Europe, or the United States for their training. Today’s University
of Montréal Orthopaedic Surgery Program still proudly bears
Samson’s name. The postwar era also saw the rise of several
other orthopaedic surgery programs in Canada.
Canada’s government-funded health-care system represents
a peculiarity in North America—one that improves the quality
of life of its citizens. Canadians enjoy free and unlimited high-quality
care, including access to top specialists, in hospitals and public
clinics from British Columbia to Newfoundland. In this regard, practicing
orthopaedic surgery in Canada is rewarding, as surgeons are expected
to give their best expertise equally to every patient on the basis
of the challenges of the case, regardless of such bureaucratic issues
as the type of insurance-coverage plan that a patient might have.
The residency in Canadian orthopaedic programs is thus conducted
in this framework of high quality-of-care standards, which are accessible to
all.
Admission to an orthopaedic residency program is as competitive in
Canada as it is in the United States. After completing four to five
years of medical school, students may apply to a program within
Canada through the Canadian Resident Matching System (CARMS), which
allows both residents and program directors to pick their top choice
by orderly ranking. Orthopaedic residencies are quite popular; candidates
are chosen on the basis of their medical school evaluations and
their general overall personal qualities and achievements, including
research credentials. In July 2001, forty-five PGY-1 residents are expected
to begin their training1. One
exception to the CARMS procedure occurs in the province of Québec,
where three universities have their own matching systems. The only
difference between the French-speaking Québec programs
and the other Canadian programs is the European orthopaedic influence,
as some of the attending surgeons in Québec undertook their
fellowships in continental Europe (France and Switzerland) and the United
Kingdom. This has resulted in the creation of a unique setting in
which different clinical visions coexist. We should note, however,
that the overall requirements and objectives of resident education
are the same in Québec as they are throughout the rest
of Canada.
Canadian programs have a five-year curriculum. In 2000, the Royal
College of Physicians and Surgeons of Canada and the Canadian Orthopaedic
Association revised their educational criteria in order to increase
the exposure of residents to orthopaedic surgery. As a result, in
the first two years, a minimum requirement of twelve months of core
surgery has been implemented. Most of the Canadian programs concentrate
solely on orthopaedics as early as the residents’ second
year and continuing all the way to the fifth. The accreditation
status of all Canadian programs is reviewed every six years by the
Royal College of Physicians and Surgeons of Canada, to ensure the
quality of training. In 2000 and 2001, there was a total of sixteen
orthopaedic programs in Canada, with a total of 285 residents (including
thirty-eight foreign trainees) and seventy-four fellows (including
forty-five foreign trainees)1.
The universities are the main subsidizer of the residency programs;
however, special educational activities are financed by additional
funds from individual attending orthopaedic surgeons and, in some
cases, by the orthopaedic industry.
The main advantages of being an orthopaedic surgery resident
in Canada are the exposure to clinical cases, the involvement in patient
management, and the increased involvement in the operating room
in the very early stages of residency. Residents in Canada perform
fewer clerical tasks than do residents in the United States, most
likely because the documentation requirements are less stringent here
than they are for our southern neighbors. The disadvantage of a
publicly managed health-care system, however, is the length of the
waiting lists, particularly for surgery. A resident who sees a patient
with an interesting clinical problem might only be able to schedule
an operation for that patient several months later, often well after
the resident has left for a different hospital.
To complete an orthopaedic surgery residency in Canada, two main
examinations are required. The first, Principles of Surgery, is
taken at the end of the second year, and the second, the Royal College
of Physicians and Surgeons of Canada oral and written examinations,
are taken during the final, fifth year. All residents must pass
the oral and written examinations in order to obtain a license to
practice in Canada. This is in contrast to the United States, where
board certification is not a prerequisite for the practice of orthopaedic
surgery. At the end of 1999, only 16,040 (74%) of 21,553
practicing orthopaedic surgeons in the United States were board-certified2. Both Canadian and American certifications
are generally reciprocally recognized between the two countries
by their respective provincial and state authorities.
A concern has been raised, among Canadian residents, about the
fact that the Royal College of Physicians and Surgeons of Canada
examinations are held in May and June of the fifth year of residency.
Final-year residents need sufficient time to study for these examinations,
which results in decreased clinical exposure during the last year
of training. Previously, the same examinations were held in the fall
of the year following graduation, which allowed additional time
for study.
As an additional method of training, Canadian programs place strong
emphasis on the ever-popular Journal Clubs, an idea first implemented
in Canada by Sir William Osler in 1875, at McGill University3. Here, as elsewhere in North America,
evidence-based medicine is an integral part of the training methodology.
Although orthopaedic surgery training in Canada meets high standards,
maintaining and improving these standards relies on continuous reassessment
of how orthopaedics is taught. Because of geographical proximity,
the Canadian and American residency programs have many similarities.
Because of the rising cost of health care in North America, changes
in medical education have occurred recently and probably will occur
in the future at an increasing rate. Training programs in the United Kingdom
are substantially different. We can learn some useful lessons by
comparing these training programs with those in North America.
After completing medical school, a student in the United Kingdom
must serve two years as a senior house officer, the equivalent of
the internship in North America, after which he or she can take
the Membership Examinations in General Surgery. Only after successful
completion of these examinations is the student allowed to apply
for higher-level surgical training positions.
The training in the specialty of trauma and orthopaedic surgery lasts
a minimum of six years and leads to a Completion Certificate of
Specialist Training4. The first
four years in training are geared toward the successful completion
of the Intercollegiate Board Examination of Orthopaedic Surgery.
The last two years provide the trainee with an opportunity to widen
his or her surgical experience and to develop a special interest
in a certain field in orthopaedics. The curriculum also provides
the possibility of training abroad for up to one year during this
last segment. Finally, the curriculum clearly delineates basic requirements
for the education of the trainee, especially in terms of the number
of educational sessions and the amount of protected research time.
The work week should not exceed seven clinical half-day sessions,
including ward rounds, clinics, and operating-room time. In addition,
a minimum of one educational session per week is required. The same
educational requirements are probably met by the programs in Canada,
but, to our knowledge, there is no specifically enforced description
of these guidelines for North American training programs.
After the completion of training, fellowships are not pursued
as commonly in the United Kingdom as they are in North America,
as opportunity to acquire such experience is provided during the
curriculum. However, in both Canada and the United States, there
is a general trend toward increasing fellowship training. According
to the American Academy of Orthopaedic Surgeons, more than 50% of orthopaedic
surgeons under the age of forty have completed a fellowship, whereas
less than 25% over the age of fifty have done so5. It is generally thought, among Canadian
orthopaedic residents, that the presence of fellows in a program
heightens the quality of the teaching experience. However, one drawback
might be the decreased exposure of the resident to surgical experience,
as the fellow often performs most of the intervention.
In the United Kingdom, the number of trainees for each region
is determined by the Specialist Workforce Advisory Group in conjunction
with representatives of other specialties, and these numbers are
then sent to Parliament for a final agreement. This is in contrast
with the Canadian system, in which the different provinces separately establish
their own quotas, which are based mostly on the availability of
limited financial resources. In Canada, this situation has already
produced a shortage of trained medical specialists in many areas
and is of great concern in these times of budget cuts and rising
health-care costs.
Finally, being a resident in orthopaedics in Canada is a great privilege
because of our access to high-quality academic training. In the
spirit of The Bone and Joint Decade, the maintenance of high training
standards relies heavily on continuous reassessment and refinement
of our teaching method. It is our responsibility to foresee changes in
the health-care system in the years to come and to make specific
adjustments in this regard.