This Resident Roundup post comes from John Ibrahim, MD, who is a PGY5 orthopaedic resident at Albert Einstein Healthcare Network, in Philadelphia, Pennsylvania. He will be attending the University of Pittsburgh Medical Center for a fellowship in Hand/Upper Extremity. Dr. Ibrahim recently completed an AO Trauma Fellowship at Lucerne Kantonsspital in Lucerne, Switzerland. He is originally from Southern California.
One of the best parts of my residency program is our senior elective. During our PGY5 year, we set up a 1 to 2-month orthopaedic elective rotation. It can be in any orthopaedic specialty, at any practice in the world.
To set the scene, it is spring of my PGY5 year. My residency is at a Level I trauma hospital that primarily treats low-income, underserved neighborhoods in Philadelphia. The cases we manage provide substantial exposure to high-energy trauma, but elective surgery cases are less prevalent. My interest and future fellowship is in hand and upper extremity. I also love to travel. So, I sought an international elective with a focus on upper-extremity trauma and elective cases. Ultimately, I decided to complete a 6-week AO Trauma Fellowship at a Level I, multispecialty hospital in Lucerne, Switzerland. It was amazing.
An international rotation is valuable for 3 main reasons: 1) it teaches you surgical techniques that are developed outside the U.S. or your home environment; 2) it broadens your mind on how to approach orthopaedics; and 3) it gives you an appreciation for the training process in medicine.
First, I was exposed to surgical techniques that I hadn’t seen during residency. The hospital I rotated at is called Lucerne Kantonsspital (think of a large academic hospital that serves the local region). Lucerne Kantonsspital is one of the pioneers of minimally invasive plate osteosynthesis (MIPO). The prior chair of the department, Professor Dr. Reto Babst, was an early developer of MIPO, first starting with the well-known LISS (Less Invasive Stabilization System) plate for distal femoral fractures. He later described MIPO approaches throughout the upper and lower extremity. His successors, Dr. Bjorn Link and Professor Dr. Frank Beeres, who are the current department heads (and also were the hosts for my AO fellowship), trained in MIPO under Babst and further developed these approaches.
One of the most impressive techniques I observed was a MIPO approach for an ORIF of a scapular fracture. But aside from the techniques themselves, the entire department had a unique approach to treating these fractures. They are a self-proclaimed “school” in the sense that the senior surgeons train the next generation of junior surgeons and trainees in these specific techniques. That leads me to the second point.
Second, I gained a unique perspective on the practice of orthopaedics, especially in an academic setting. The idea of the hospital being a “school” of a specific style of orthopaedics (minimally invasive, soft-tissue friendly) means that all the surgeons have to be unified both in their thinking and practice. Cases are done in a relatively standardized way. All geriatric intertrochanteric hip fractures are treated with a cement-augmented helical blade. Distal radial fractures are generally fixed using the same reduction tools and in a predictable order. It makes it reproducible for the trainees and streamlines processes for the operative staff. Regardless of the head surgeon, the steps are relatively the same for the entire OR team. Of course, there are advantages and disadvantages to this, but it did expose me to one way of running a department. And it also demonstrated one way of training—the idea of a “school” or what others call a “training pedigree”. The Lucerne school, for example, stems from the teaching of Babst, and now from Link and Beeres.
Third, the training program at Lucerne, as previously mentioned, is relatively standardized in terms of the steps of performing a specific procedure. However, almost all the trainees and surgeons there have some outside training experience, which gives them additional perspective. It is this perspective that I gained by going to Switzerland that I find so valuable. For example, after completing his residency, Bjorn Link completed a yearlong AO Trauma Fellowship in Australia. Frank Beeres completed his residency in the Netherlands and did a short AO Trauma Fellowship at Lucerne prior to joining the staff at Lucerne Kantonsspital.
Furthermore, the Swiss residency system requires residents to rotate at different hospitals of varying levels of acuity; a Level I trauma rotation is required, as is a rotation at a suburban, community hospital. Another example demonstrates the European regional differences in practice: the elective shoulder surgeon at Lucerne, Dr. Roland Camenzind, is a Swiss native with training in both Swiss and French styles, so his style of shoulder surgery is French, including arthroscopy without cannulas, the beach chair position for almost all operations, and a preference for bone augmentation rather than metal augmentation during arthroplasty. He made it a point to mention that it would be rare to find a local surgeon performing these procedures in a different style.
This academic travel does 2 main things for trainees: 1) it provides an outside perspective on both techniques and the hospital system as mentioned above, and 2) it fosters an environment of hosting visiting trainees and of teaching and learning new ideas from others. This type of academic hospitality is something I hope to be a part of in the future, where I could host visiting trainees while I’m still training in Pennsylvania, or in California, where I plan to practice.
For a junior resident interested in an international rotation who may be reading this, one piece of advice is to start investigating these options early. I set up this rotation almost one year in advance and needed specific prerequisites to be considered for an AO Trauma Fellowship. My application and rotation required AO Trauma Basic Principles and Advanced Principles courses and an international work visa, among other requirements. Some residency programs have an imbedded international rotation through partnerships created by the individual institution, but if this is not an option at your program, several international options exist outside these exclusive partnerships. Some examples include international training opportunities in trauma (AO Trauma Fellowship); shoulder (Alps Surgery Institute); arthroplasty (The Knee Society; M.E. Müller Foundation of North America; European Knee Society); and sports (European Society for Sports Traumatology, Knee Surgery and Arthroscopy). Acceptance to these programs often is accompanied by funding or a stipend, which helps to alleviate the cost of an international rotation. In a 2020 JAAOS article1, 51 of 102 surveyed orthopaedic residency programs reported an opportunity for a global elective, so many U.S. trainees may have the opportunity to participate in an international rotation.
Now that I’ve returned home, I have a renewed appreciation for orthopaedic care. Of course, my residency training provides my foundation, but the new ideas that I learned have broadened my perspective. Now when I evaluate a patient, I have a larger orthopaedic toolbox at my disposal to provide my patients with the best treatment plan. My experience was a pleasant reminder that orthopaedics truly is an international community where local factors influence treatment and can produce different strategies for a single pathology. And more importantly, the international relationships that I made with the residents and surgeons abroad is hopefully the start of a lifelong partnership.
John Ibrahim, MD
Photo: Drs. Björn Link (Head of the Department), John Ibrahim, and Frank Beeres (Director of Fellows) at Lucerne Kantonsspital.
References
- Pfeifer J, Svec N, Are C, Nelson KL. Rising Global Opportunities Among Orthopaedic Surgery Residency Programs. J Am Acad Orthop Surg Glob Res Rev. 2020 Dec 14;4(12):e20.00102.
