An Orthopedic Rotation – Kiwi Style

By Greg Hildebrand Auckland, New Zealand

• Auckland population: 1.614 million (2016)

• Total NZ population: 4.794 million (2017) Auckland City Hospital

– New Zealand’s largest public hospital and clinical research facility – Largest tertiary referral center in New Zealand and smaller surrounding Polynesian islands – Outpatient clinics held at Greenlane Clinical Centre – Clinical teaching site for the University of Auckland Orthopedic Surgery

– My international elective was in orthopedic surgery – Majority of my time on site was spent at Auckland City Hospital in the orthopedic theatres (OR) – Pictured to the left is Mr. Twaddle, one of the consultant orthopedic surgeons I had the pleasure of working with – Long story short, he had worked with my dad (also an orthopedic surgeon) in the states around 30 years ago Topic of Interest – Medical Training in NZ

– This became my topic of interest because during the first two weeks of my rotation, I was not allowed to scrub in – This confused me due to the fact medical students back in the states scrubbed in everyday – I then realized that medical students, house officers, and even some junior registrars did not routinely scrub in – Due to this, I became intrigued about medical training in NZ and I wanted to learn more A Comparison – US vs NZ

USA Medical Training New Zealand Medical Training – Medical student – 4 years – Medical student – 6 years House officer – 2 years – Resident – 3 to 7 years – – Junior registrar – as many years as it – Fellow (if applicable) – 1 to 3 years takes to make senior registrar (usually around 3 years) – Attending – Senior registrar – 3 to 5 years – Fellow (if applicable) – 1 to 3 years – General physician or Specialist Stages of Training in NZ

– Medical student – Undergraduate degree NOT required – Total of 6 years with 3 being academic and 3 being clinical – House Officer – After graduation, students can apply to become a house officer and will be placed at hospitals throughout New Zealand – Total of 2 years with 3 month rotations of different specialties (8 rotations total) – Have NOT declared for a specific specialty at this time – Main responsibility of doing the grunt work for the registrars – Rounding, writing notes, taking admissions, etc. – Not allowed to scrub in for surgery (when on surgical rotation) Stages of Training in NZ (cont.)

– Junior registrar – Applicants are eligible to apply 2 years post-graduation, essentially after completing 2 years of being a house officer – At this point, you HAVE declared and applied to a specialty – Role in orthopedics: oversee the house officers, scrub into limited surgeries – This is the catch: you can be a junior registrar forever – E.g. one junior registrar on the orthopedic service had been there for 14 years – Senior registrar – To become a senior registrar, you have to be in the top 15% of your junior registrar class – Total of 3 to 5 years depending on the specialty – Role in orthopedics: scrub into all surgeries, teach the junior registrars – As attending surgeons rarely scrub in, senior registrars perform the majority of cases unaided In Conclusion

– Pros of medical training in NZ: – A broad spectrum of training longer into their careers – More autonomy in the operating room as a senior registrar – Cons of medical training in NZ: – Duration of training including medical school: average of 7-11 years in the US with the average being 12-14 years in NZ – Lack of any specialty experience earlier in their training – Biased conclusion of a US trained medical student: – Training in the US is superior to that in NZ because of the medical school structure and more specialized training earlier in the career – In my own biased opinion, as a 4th year medical student I feel comparable to a house officer in the NZ medical training scheme Most profound clinical experience

– I was lucky enough to be a part of a case where biomedical engineers constructed a 3D image of a patient’s ilium – This allowed them to construct a hip arthroplasty that fit his ilium or his “hip socket” perfectly – The physicians and biomedical engineers went to all this trouble because this patient had already gone through a failed total hip arthroplasty and they wanted to make sure they got it right this time – This was my favorite clinical experience because I had never seen orthopedic surgeons and biomedical engineers work together in the OR before Most profound cultural experience

– The Maori People – The Maori are the indigenous people of New Zealand – I was fortunate enough to attend a traditional Maori feast and ritual one weekend in Rotorua – We learned about traditional face markings, home decorations, and rituals important to the Maori people – Most importantly, we learned about their origins and how they were colonized by the British and forced to sign treaties they didn’t want to be a part of – Sound like anything else in American history? Pictures References

– Interviews with: Dr. Stewart, Mr. Twaddle, Mr. White – https://www.mcnz.org.nz/get-registered/registration-policy/special-purpose- scope-policy/post-graduate-training-requirements/ – https://medicfootprints.org/new-zealand/medical-academic-training- opportunities-nz/ – http://learnanythingfree.com/celebration-happiness-45-maori-haka-new- zealand/ – http://www.justmaps.org/maps/oceania/newzealand/auckland.asp – Greg’s iphone: every picture except for maps and maori culture picture