Nicaragua is the largest country in Central America, with a population of 6.1 million people. A period of war and economic decline in the 1980s has been followed by one of reforms and stabilization, gradually improving the lives and health of the people. However, Nicaragua is still a poor country with very limited resources available for health care.

Even while facing enormous challenges, Nicaragua has had considerable success in improving the health of the general population in the past three decades. Better access to safe water, sanitation, and immunization services has increased life expectancy and decreased infant mortality.

As the population continues to grow, the proportion of older people will increase, and birth rates will decrease. These trends will have a significant impact on the demand for health services, particularly with regard to orthopaedics.

Physician training
Applicants to study medicine in Nicaragua start a 6-year medical school program immediately after graduating from high school. The medical course is offered in both public and private universities in the cities of León and Managua. Admission to medical school is based on a written national examination and skills evaluation.

The first 3 years of study focus on the basic sciences, and during the following 3 years, students serve clinical rotations in internal medicine, pediatrics, obstetrics, surgery, and specialties.

The last year of study is an internship in certified hospitals. Following the internship, each student is required to perform 2 years of social service, during which the young doctors are assigned to rural areas throughout the country. The social service work is focused on primary care and preventive health services, pregnancy care, pediatric care, vaccination, and treatment of patients with chronic health conditions, among other services. The doctors in training may also have administrative and teaching duties during their social service.

The duration and place of social service are considered in the selection process of medical and surgical residencies. Students who do their social service in remote, underserved areas are given an advantage during the selection process for postgraduate studies. Once the social service has been completed, students are eligible to submit their thesis and receive their medical degree.

Residency training
Once qualified as a physician and surgeon, young doctors who wish to study orthopaedic surgery compete for admission to residency programs in orthopaedics and trauma surgery. In Nicaragua, every young doctor must choose between two paths to gain admission to a specialty training program; one is administered by the Ministry of Health (MINSA), and the other by the National Autonomous University of Nicaragua (UNAN).

Half of the orthopaedic residency positions available each year are filled by candidates selected by MINSA, and the other half are selected by UNAN. Both MINSA and UNAN base selection primarily on test scores (70 percent), although grades (20 percent) and social service and other factors (10 percent) are also taken into account.

Orthopaedic and traumatology training focus on the skills and knowledge that residents need to manage common medical and surgical problems encountered in the country. In all accredited hospitals, residents rotate on 24-hour shifts in the emergency department. Resident oversight and surgical care is provided by a member of the orthopaedic department.

In February 2015, 55 residents, including 10 women, were enrolled in orthopaedic surgery training in the five accredited residency programs. Currently, most residency programs consist of 3 years of training, but there is widespread agreement that 4 years of training is desirable.

First-year residents are introduced to managing trauma of the musculoskeletal system, the fundamentals of surgical care, principles of radiology, and ambulatory and hospital care. Second-year residents continue to focus on trauma management and are introduced to reconstructive surgery, intensive care, and clinical-radiologic correlations. Third-year residents focus on orthopaedic pathology of upper and lower extremities, pediatric orthopaedics, and biomechanics. In 4-year programs, residents spend the final year focused on orthopaedic specialties, fundamentals of spine surgery, joint replacement and arthroscopy, and studies of specialized imaging modalities.

Residents in an accredited hospital cannot train in another hospital or program. Although no postresidency specialty training programs (fellowships) are available in Nicaragua, some residents complete specialty training programs in other countries.

Each training program has its own methods of assessing resident progress. For example, in the Hospital Escuela Oscar Danilo Rosales Arguello in León, residents perform three written tests and a practical assessment to qualify for promotion. In the practical assessment, the faculty selects a surgical case and evaluates the resident based on his or her performance of preoperative planning, surgical intervention, and postoperative patient care.

Bringing the OITE to Nicaragua
In 2014, through a pilot program endorsed by UNAN, Nicaraguan Association of Orthopedics and Traumatology (ANOT), and MINSA, the AAOS orthopaedic in-training examination (OITE) was given to the first group of Nicaraguan orthopaedic residents. The pilot program was considered a success, and the 2015 OITE examination will be administered in November.

According to data supplied by ANOT, Nicaragua has 219 male and 16 female orthopaedic surgeons. Of the total 235 orthopaedic surgeons in the country, 210 are actively practicing and 25 are retired or inactive. This results in approximately 3.5 orthopaedic surgeons for every 100,000 people—less than half the average population density of orthopaedic surgeons in the United States.

Nearly half of all orthopaedic surgeons in Nicaragua practice in the capital city of Managua. The rest work in smaller urban areas, including León, Chinandega, Rivas, Matagalpa, and others. Approximately 75 percent of orthopaedic surgeons are members of ANOT.

In summary, Nicaragua is the largest country in Central America. Although it has limited resources for training doctors and providing health care, great progress has been made, especially in the areas of preventive health services, immunizations, access to water, and sanitation. One of the many challenges facing the country is how to improve the availability and quality of specialized medical care, including orthopaedic surgery, to keep pace with a growing and aging population.

The education of orthopaedic surgeons in Nicaragua is accomplished in a well-organized system that provides the resident selection methodology, training, supervision, and evaluation. Further improvements are expected in the coming years, including the expansion of residency training to 4 years and the development and implementation of a nationwide in-training examination to assess the progress and competence of orthopaedic residents and training programs.

Dr. Gustavo Rodriquez is the president of ANOT; Dr. Eduardo Centeno is a fellow at the International Center for Orthopaedic Education; Henry DeGroot, MD, is an instructor in orthopaedics at Tufts University Medical School in Boston and clinical associate professor of orthopaedic surgery at the University of Massachusetts Medical School, Worcester, Mass.

Did you know…?

• In 2011, total combined public and private healthcare spending in Nicaragua was $296 per capita, compared to $8,608 per capita in the United States.
• More than half (51 percent) of the population in Nicaragua is younger than age 24.
• Nicaragua has a higher percentage of female Sorthopaedic surgeons (6.8 percent) than the United States does (5.7 percent).