Orthopaedic residents are increasingly interested in oversea rotations. Unfortunately, no guidelines on how to establish these rotations are available and only a few residency programs offer oversea opportunities. Moreover, current Accreditation Council for Graduate Medical Education (AGCME) rules do not permit programs to give credit for oversea rotations. So why should an orthopaedic resident give up valuable vacation time for an oversea rotation?

An oversea elective is a great way to nourish cultural awareness, professionalism, and resourcefulness. Residents will see a variety of pathologies that they may never encounter in the United States.

Unfortunately, many U.S. and Canadian orthopaedic residency programs do not offer the opportunity for an elective rotation abroad. The major stumbling blocks to such programs are time, lack of ACGME accreditation, and funding. Residents are a very valuable commodity in the hospital setting. Many programs simply do not want to "lose" a resident for a month or pay to send someone abroad.

Recently, a web-based survey on international electives was sent to 179 U.S. orthopaedic residency programs. Of the 56 programs that responded, 18 offered an international elective, and 14 of those programs partnered with an oversea academic institution. However, just 12 programs offered financial assistance.

The AAOS Resident Assembly recently conducted a similar survey among 210 U.S. and Canadian programs, which generated a 28.1 percent response rate (n = 59). Nearly half (29) of the responding programs gave residents the opportunity to volunteer abroad. Most (22) offered medical missions, one program offered rotations in a medically advanced country, two programs offered both, and four programs specified "other."

Programs funded these opportunities in a variety of ways, including department funds (12), scholarships (3), and funding from medical or military missions (9), faculty, industry, philanthropy, or a combination of sources. Five programs specified that residents raise money on their own.

The average time away was 3.14 weeks, and most participating residents were in their PGY-4 or PGY-5 year. Interestingly only seven programs required their residents to use their vacation time for an oversea rotation.

Programs listed a number of reasons for sending residents overseas, including experience with cultural differences, access to different theories of learning, introduction to different pathologies, and opportunities for humanitarian efforts.

The orthopaedic surgery residency program at the University of California, San Francisco (UCSF), for example, uses a combination of ways to enable PGY-4 residents to overcome the major challenges of time and funding. During a 3-week oversea rotation, 1 week is taken from hospital rotation, 1 week from personal vacation time, and 1 week from educational leave by the home institution.

Funding for travel expenses for the UCSF program comes from several sources, including department funds, donations from the private sector, industry support, and an Orthopaedic Research and Education Foundation Grant.

A well-planned international elective should easily meet the core competency requirements established by the ACGME. For example, residents would be required to keep a log of all surgical cases, similar to the current case log they use for their U.S. training. At the conclusion of the rotation, case logs should be reviewed by the program director to ensure that educational objectives have been achieved. This will also ensure that the work hour requirements have not been violated.

The AAOS Resident Assembly Global Health Initiative (GHI) is designed to help establish guidelines for orthopaedic residents who are interested in academic or volunteer oversea rotations. Its goal is to establish funding resources that will provide travel scholarships for residents from U.S. and Canadian programs. The GHI will also help programs establish guidelines that will enable residents to travel abroad for a dedicated amount of time and comply with AGCME requirements. Ideally some of these goals should be accomplished within the coming year. Residents who are interested in becoming involved with the GHI can contact Kristen Erickson (Erickson@aaos.org).

Verena M Schreiber, MD, is a PGY-6 resident at the University of Pittsburgh Medical Center and a member of the Resident Assembly Executive Committee.

References:

1. Rovinsky D, Coughlin R: If there's a will, there's a way. AAOS Now June 2008.
2. Fan B, Zhao C, Sabharwal S: International elective during orthopaedic residency in North America: Perceived barriers and opportunities. J Bone Joint Surg Jan 7;97(1):e1. doi: 10.2106/JBJS.N.00012.