|Year : 2018 | Volume
| Issue : 1 | Page : 8-11
Orthopaedic subspecialisation: The Nigerian experience
Peace Ifeoma Amaraegbulam
Department of Surgery, Federal Medical Centre, Umuahia, Abia State, Nigeria
|Date of Web Publication||30-Jul-2018|
Dr. Peace Ifeoma Amaraegbulam
Department of Surgery, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Purpose: Globally, Orthopaedic Surgery is not left out in the trend towards subspecialization in the surgical specialties. This study aims to determine the current perception and practice of subspecialization in Orthopaedics by the Nigerian Orthopaedic surgeon and to make recommendations on the way forward. Methods: A questionnaire was designed and distributed among Orthopaedic surgeons of different cadres. One hundred and twenty (120) questionnaires were sent out and 107 of those were recovered. Their responses were collated and the resulting data was analyzed using the IBM SPSS version 21. Results: One hundred and three (103, 96.3%) of the respondents were males and 4 (3.7%) were females. Eighty-eight (88, 82.2%) were consultants; 98 or 91.6% worked in government facilities. Thirty-eight (38, 35.5%) said they were subspecialists. Ten (10) had subspecialty training 6 months or longer. Nine (9) had more than 75% of their practice in their subspecialty. Twelve (12) subspecialists were satisfied with their level of knowledge while eleven (11) were satisfied with their output. Most of the respondents (103, 96.3%) desired that the subspecialty training should be made mandatory while 102 (95.3%) wanted it incorporated into the regular Orthopaedic training in Nigeria. Conclusions: There is need to standardize the definition and training of Orthopaedic subspecialists in Nigeria, in order to improve the quality of practice and enhance the output and satisfaction among subspecialist surgeons. Postgraduate training in Orthopaedic subspecialties is advocated.
Keywords: Nigeria, orthopaedic, perception, subspecialisation
|How to cite this article:|
Amaraegbulam PI. Orthopaedic subspecialisation: The Nigerian experience. Niger J Orthop Trauma 2018;17:8-11
| Introduction|| |
The whole practice of medicine has been traced to have been one, with a gradual but progressive fragmentation to the different specialities as we have today. Surgery, which started as a single practice has persistently had branches split off from it till today when even the surgical specialities are also undergoing subspecialisation. Globally, Orthopaedic surgery is not left out in the trend towards such subspecialisation in the surgical specialities. It is said to have grown from one subspeciality, Hand Surgery, branching off till the current state where there are up to 26 subspecialities. Many reasons have been adduced for subspecialisation including the skill development, better employment opportunities, monetary rewards and even being part of a trend. Different authors have argued over the pros and cons of subspecialisation, especially hinting on the fragmentation of the parent subspeciality.,,,
Rockwood opined that orthopaedics could become a threatened species like the parent General Surgery due to the excessive subspecialisation.,, Sarmiento also feared for the effect of subspecialisation on the associations of Orthopaedic Surgeons.
In Nigeria, this wave of choosing a subspeciality is also practiced by surgeons of different age groups. Among the younger ones, it is seen as a mark of purpose and achievements for one to be interested in subspecialisation and to go for further training in such areas, not minding how short the training is. Whereas, the duration of the post-residency fellowships is standardised to 1–2 years depending on the subspeciality,, there is no such guideline in the acceptable length of training nor even in the content of practice.
This study aims to determine the perception and current practice of subspecialisation in Orthopaedics by the Nigerian surgeon and to make recommendations on the way forwards.
| Materials and Methods|| |
Structured questionnaires were distributed to participants at the 2016 Annual General and Scientific Conference of the Nigerian Orthopaedic Association, a pilot study having been done earlier through online questionnaires sent to members.
The completed questionnaires were retrieved and the responses collated and analysed using the IBM SPSS version 21 (IBM Corp. Released 2012, IBM SPSS statistics for Windows, version 21.0. Armonk, NY. IBM Corp). I analysed the information for the demographics, whether the respondent regarded him/herself as a subspecialist or not, the subspeciality of interest and the motivation for choosing such subspeciality. Further, information analysed included how many respondents had taken a post-residency training in their subspecialities and for how long, whether they were satisfied with their level of knowledge and output in the different subspecialities, followed by the response on whether or not they desired subspecialisation in the country and whether or not subspecialisation should be made mandatory.
The confidence level of 95% was taken, and the results were considered significant for a P < 0.05.
| Results|| |
There were 107 respondents, of whom 103 were male (96.3%) and 4 were female (3.7%). The mean age was 44.10 ± 2.3 years. Ninety-one respondents (91, 85.0%) were post-residency, either working as consultants (88, 82.2%) or yet to be appointed (3, 2.8%). Ninety-eight persons (98, 91.6%) worked in the government hospitals, either working only for the government (64, 59.8%) or combined such with working in private and mission hospitals (34, 31.8%). Thirty-eight respondents (38, 35.5%) considered themselves as subspecialists; 65 (60.7%) said they were not subspecialists, while 4 (3.7%) were not sure whether they were subspecialists or not [Table 1]. Trauma (47.6%) and joint reconstruction (36.4%) were the most preferred subspecialities. The most people chose more than one subspeciality, and it was difficult to infer which was preferred over the others. The most common reasons for subspeciality choice were inspiration by a mentor (29, 27.1%), humanitarian reasons (28, 26.2%) and improved work opportunities (26, 24.3%). Fifty (50, 46.7%) respondents, 24 of whom considered themselves as subspecialists, had acquired some post-residency training in their subspeciality areas of interest (Chi-square 0.03, P < 0.012).
Ten of those who had post-residency training had spent more up to 6 months on such training. The others spent varying periods of time with the least having spent less than a month. Twelve (12, 31.6%) of the subspecialists had <25% of their practice in their areas of subspeciality interest, 17 (44.7%) had 25%–75% content, while 9 (23.7%) had more than 75% content [Table 2]. Twelve subspecialists were satisfied with the level of knowledge in their subspeciality, compared with three non-subspecialists who were satisfied with their knowledge in their areas of interest [Table 3]. Eleven subspecialists were satisfied with their output in their chosen subspeciality areas compared with three non-subspecialists who expressed satisfaction with their level of output in the subspeciality of interest [Table 4].
|Table 2: Comparing the percentage of content practice of the respondents|
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|Table 3: Comparing surgeon's satisfaction with the level of knowledge among the different groups|
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|Table 4: Comparing surgeon's satisfaction with the level of output among the different groups|
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One hundred and three (103, 96.3%) of the 107 respondents agreed that post-residency fellowships were desirable in Nigeria, and 102 (95.3%) would want it incorporated into the residency program.
| Discussion|| |
Orthopaedics is largely a male-dominated field, so the low number of female respondents was appreciated. The mean age and the consultancy status of most of the respondents suggested that they could give reasonable responses to the subject at hand.
About a third of the respondents claimed to be subspecialists, while more than half of the group said they were not subspecialists. The big question is whether the two categories had the same concept of who a subspecialist was since there were no guidelines on subspecialisation in Nigeria. This probably mirrored what obtained in India, where it was difficult to set guidelines for practice. It appeared that many equated being a subspecialist with having an interest in one subspeciality or another. This is further supported by the fact that two-thirds of those who claimed to be subspecialists had post-residency training, while a third of those who did not think themselves subspecialists also had some post-residency training.
Trauma and joint reconstruction were the topmost choices of subspeciality in this study. This was contrary to Sarmiento's observation that Sports Medicine was the 'darling of the crowd'. The difference in likes of subspecialities among the surgeons could have been influenced by the pattern of patient presentation.
Inspiration from a mentor, humanitarian drive and improved employment opportunities were the most common reasons that influenced the choice of subspecialities in our study. Similarly, in their studies, Almansoori and Clark  and Daniels and DiGiovanni  also found employment and market forces to rank high among the reasons people choose fellowships.
Apparently, the perception of whether one was a subspecialist or not was merely subjective, probably because of there was no set guidelines to determine who was a subspecialist. There was no clear consensus on whether a post-residency training was required or not, as different authors had varying opinions on that subject.,, Furthermore, this could demonstrate a quest for knowledge more than status. It was not clear whether this trend contradicted Sarmiento's claim that subspecialisation was not beneficial  or supported Almansoori's study that the most important reason for subspecialisation was surgical skill development.
The American Academy of Orthopaedic Surgeons defined the categories of practice as follows: a generalist treats every orthopaedic patient; a generalist with a subspeciality interest has at least 25%, but <75% of his practice in an area of subspeciality interest, while the subspecialist has more than 75% of his practice committed to an area of subspeciality interest. Going by this definition, it could be inferred that only about 25% of respondents who defined themselves as subspecialists were actually subspecialists. Majority of them would, at best, be described as generalists with subspeciality interest.
About a third of those who defined themselves as subspecialists were satisfied with their level of knowledge in their subspeciality, and about the same proportion was satisfied with their output in their chosen subspeciality of interest. Could this have resulted from inadequate exposure to the subspeciality during the period of residency training? Or could it also be that even the post-residency training period was not adequate, considering that <10% of respondents had such trainings lasting up to 6 months at a time. The most countries adopted the William Halsted model of the 1800s where residency was 'a series of apprenticeship under different surgeons followed by 1–2 years of post-residency fellowship.' Sarmiento, however, opined that the length of fellowships should not be standardised as 1 year since, in his opinion, 3 or 6 months could be sufficient for the interested surgeon to gain the desired additional knowledge. In our case, the short periods of post-residency trainings could have been due to the poor availability of such centres in the nation. Consequently, those who wanted to acquire knowledge in their fields of interest often had to travel abroad, and oftentimes, this was done at their own cost.
It was understandable that almost all the respondents thought that post-residency fellowship was desirable since a significantly higher percentage of those who defined themselves as subspecialists reported a higher level of satisfaction in level of knowledge and output compared with those who were not subspecialists. Work and output satisfaction must really be an important factor in the lives of these surgeons. However, though the majority would want to see post-residency fellowship training made mandatory through incorporation into the residency program, I prefer to align with Sarmiento on this. Subspeciality fellowships should neither be compulsory nor have a mandatory period assigned to it.
I suggest that clear guidelines be set to define who a subspecialist was and what minimum training was required for one to be awarded such status. Collaborations between different orthopaedic centres, or perhaps the National Orthopaedic Association and centres where such subspecialities are established could possibly help in developing the standard of care in the nation. This would facilitate the undertaking of these fellowships by more surgeons who are interested in it.
However, it is not unlikely that subspecialisation would lead to a dearth of Orthopaedic surgeons in Nigeria. Currently, there are only 350 orthopaedists for a population of more than 180 million and these few surgeons practice mainly in the large cities. With subspecialisation, the poor access to basic care noted by Muzumdar  in their study would probably be worse in our environment.
Perhaps, a better practice might be Muteti's suggestion whereby a balance is struck with generalists having interests in certain areas. In any case, generalists are not lesser mortals. After all, great advances in orthopaedics had been ascribed to generalists such as John Charnley, Paul Harrington, Maurice Muller and Masaki Watanabe.
On the effects of subspecialisation on the Nigerian Orthopaedic Association, one could also worry about 'subspecialisation weakening the glue that held us together' more so as the association still has a lot of work to do in arousing the interest of her members in her activities. Is it not likely that the little progress she is trying to make in this area would be eroded when subspeciality associations start roaring?
| Conclusion|| |
The perception of subspecialization is still individualized among the Orthopaedic surgeons in Nigeria. There is need for standardization of this concept to facilitate an improvement in practice. Postgraduate training is required to enable Orthopaedic surgeons to improve in their knowledge of the subspecialties.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]