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Dr. Tonino: As a faculty member and course director for AAOS international programs, I have witnessed the tremendous growth of these programs. Our success has enabled us to expand into several countries in South America, Europe, Africa, and Asia. The courses expose orthopaedic surgeons from other countries to the American orthopaedic educational system.


Published 12/1/2008
Annie Hayashi

Sharing our wealth of knowledge

International courses offer faculty a “worldly” experience

In 1994, the Academy held just one educational program outside the United States. Fifteen years later, in 2009, the AAOS will coordinate nine educational programs across the globe, involving 60 or more faculty members.

That global reach has helped add 4,522 international affiliate mem­bers to the Academy’s membership rolls and attract nearly 4,000 international visitors to the AAOS Annual Meeting each year. It has also helped fuel a market for Academy materials, including books, electronic media products, and patient education brochures. More importantly, though, it has brought expert orthopaedic education to physicians around the world who otherwise would not have had the opportunity to learn and improve their surgical and patient care skills.

AAOS Now senior science writer Annie Hayashi sat down with International Committee member Pietro M. Tonino, MD, and international faculty members Douglas E. Padgett, MD; Diane Lynn Dahm, MD; Rafael J. Sierra, MD; and Timothy J. Bray, MD, second president-elect, Orthopaedic Trauma Association, to discuss their varied experiences as course directors and faculty members in international venues and the impact global outreach has had on them professionally and personally.

Ms. Hayashi: What has your experience as a faculty member or course director of an AAOS international program been?

In addition to being able to teach others, we have learned from surgeons in these countries—often finding that they have far more knowledge than we assumed. It is a highly collaborative process—surgeons learning from as well as teaching surgeons.

Dr. Padgett: I initially had the typical ugly American viewpoint: In developing countries, physicians have a basic level of medical knowledge, below our own. I quickly found that their background knowledge was well above my preconceptions

Dr. Dahm: Last summer I went to Guatemala. It was my first experience as a faculty member. I was very impressed with the excellent knowledge base many of the local physicians had acquired through their local training and also through online access to medical journals.

Ms. Hayashi: What kind of access did local orthopaedic surgeons have to orthopaedic devices or technology?

Dr. Bray: I agree. Many of the countries do not have the economic resources to enable physicians to perform the high-tech procedures that we take for granted. But sharing updated information gives the physicians a good idea of newer thinking.

Dr. Padgett: I was a faculty member in 2006 with a rather large American delegation that went to Thailand for a meeting with attendees from all over the Southeast Asian region. Last summer, I was the course director in Colombia. Thailand and Colombia have embraced the new technology. Our faculty was able to demonstrate how the principles of evidence-based medicine can be used to evaluate the various implants, devices, and other orthopaedic technology.

Ms. Hayashi: Your comments reflect two levels of programs—one for countries with access to technology and a more humanitarian mission to countries with fewer resources.

Dr. Tonino: That’s right. In Argentina or Colombia, the surgeons have access to technology. That course is different from a humanitarian program. But both are needed and very beneficial.

Dr. Dahm: In Guatemala, we were asked to focus on open repair techniques because of the limited access to arthroscopy and technology. Although we covered arthroscopic techniques in the program, we concentrated on open techniques. I think it is important to focus on getting the best and most reliable result for the patient given the available resources.

Dr. Tonino: As a faculty member and course director for AAOS international programs, I have witnessed the tremendous growth of these programs. Our success has enabled us to expand into several countries in South America, Europe, Africa, and Asia. The courses expose orthopaedic surgeons from other countries to the American orthopaedic educational system.
Dr. Dahm: In Guatemala, several surgeons were required to share a single arthroscope. When it broke, all arthroscopic procedures were cancelled until they could afford to purchase another one. In our facility, as in many others, we have arthroscopes that are used solely for teaching and laboratory purposes. The difference is profound.
Dr. Sierra: I was a faculty member in Colombia and the course director for our trip to Ecuador. In Ecuador, access to orthopaedic implants is limited in public hospitals. Patients or families have to pay for their implants prior to surgery. In some cases, instead of commercially manufactured external fixators, physicians used fixators crafted by local artisans, which have worked well for fixing complex open fractures.
Dr. Bray: The case presentation format worked well for us and our hosts. We went to a large county hospital during our last trip to Kuala Lumpur and all of us really enjoyed the opportunity to make bedside rounds and examine patients with the students at their hospital. It also gave us a chance to meet the nurses and local staff.
Dr. Padgett: We can have a tremendous impact in the less-served areas of the world—Africa, Vietnam, and Central America—where the educational opportunities are limited. In more sophisticated countries, we make a different but valuable contribution—teaching evidence-based medicine and how to evaluate and use orthopaedic technology.

Ms. Hayashi: Do you use case presentations during the programs? Can you describe a case that was particularly noteworthy?

Dr. Tonino: I met a child in Peru who had an obvious osteogenic sarcoma and needed a biopsy. The right treatment was clear. But his family and many others had walked for 2 days through the mountains just to be seen in the clinic. Even those who are seen may not be able to afford the type of care needed. It’s a very sad situation.

Ms. Hayashi: What impact has your participation had on you professionally?

Dr. Tonino: When you go to places like Peru, you learn how to do the same surgery with a lot less money. You realize that surgeons are able to do much more in a cost-effective manner and achieve very similar results.

Dr. Dahm: That was certainly my experience in Guatemala, where the cost of an implant significantly affected the choice of surgical technique. For example, osteotomy was often favored over total knee arthroplasty for medial compartment degenerative arthritis. For femoral neck fractures, unipolar prostheses were used more often than bipolar prostheses.

Dr. Sierra: In the countries that I visited, many gifted surgeons did incredible work with limited technology. The programs made me realize how fortunate we are in having the most up-to-date technology.

Ms. Hayashi: What do you see as the benefits of Academy-sponsored international educational programs?

Dr. Bray: I think the friendship we can offer and education on cutting-edge technology are the two major benefits.

Dr. Tonino: The international programs have really influenced the Academy’s Annual Meeting. Walk through the exhibit hall and close your eyes. Listen to all the languages that are spoken. It’s a whole different environment than it was 10 years ago. It’s quite amazing.

Dr. Dahm: Our international colleagues have a lot to teach us and getting them more involved in our Academy meetings is very beneficial.

Ms. Hayashi: Do you have any­thing else you would like to add?

Dr. Tonino: These international programs are such a great experience. The programs are so well-organized and the faculty is well cared for. The AAOS international department takes the lead and works out the details. The result is a highly rewarding educational program for all the participating surgeons.

Dr. Dahm: I would encourage AAOS fellows to participate. I had a very positive experience and the planning by the AAOS staff was unbelievable. Every step of the way, every detail was anticipated and addressed.

Dr. Sierra: These international educational programs are an important part of the Academy’s mission. I believe it is incumbent upon us to share our knowledge with countries that have fewer resources than ours.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org