Train-the-trainer program focuses on advanced techniques
In Romania, a country with a population of 20 million, surgical shoulder procedures are uncommon, with fewer than five shoulder arthroplasties performed annually. Although Romanian orthopaedic surgeons are technically skilled in other areas, they require more knowledge and experience to perform complex surgical shoulder interventions.

The need for additional training on shoulder techniques was identified during a 2013 AAOS combined shoulder program with the Romanian Society of Orthopaedics and Traumatology (SOROT). In response, AAOS faculty members Guido Marra, MD, and William B. Stetson, MD, together with local program coordinators, Radu Prejbeanu, MD, PhD, and Jenel Patrascu, MD, PhD, proposed the AAOS-Romania Shoulder Program.

Developed in partnership with the Victor Babeș University of Medicine and Pharmacy and the Spitalul Clinic Județean de Urgență Timișoara, the AAOS-Romania Shoulder Program is a unique 3-year train-the-trainer program that includes 3 days of advanced training for local faculty and a 2-day comprehensive shoulder course.

Since the program's inception in 2015, Drs. Marra and Stetson have trained seven local faculty members. The advanced training includes lecture development, case-based learning, and clinic patient assessment. American and local faculty then collaborate to teach a 2-day comprehensive course to orthopaedic surgeons in Romania. English is the language of learning in the region, so the course is taught entirely in English. The course, which includes an introduction to shoulder arthroscopy and arthroplasty, teaches participants the current techniques used in the surgical management of shoulder trauma, instability, and rotator cuff disease. It features Sawbones and knot-tying stations and surgical video demonstrations with small group discussions. Many participants who never had the opportunity to practice on these types of models have expressed a desire for more hands-on skills workshops.

Each year the AAOS-Romania Shoulder Program has attracted more than 75 surgeons from the region, ranging from residents to established specialists. The 2016 program was held April 21–22, in Timișoara, Romania. Adhering to the train-the-trainers model, local faculty played a more significant teaching role this year, compared to 2015. After the program's third year, local faculty will run the course independently.

"The highlight of this year's course was far and away the local faculty," said Dr. Stetson. "They did a fantastic job. They were energetic, interested, well-versed in shoulder pathology, asked great questions, and did a great job with the lectures and course at the end of the week. They have made huge strides."

Participants also give the program high marks, with 99 percent saying they would recommend it to a colleague.

As part of the program, each year, one or two local faculty are selected to participate in an observership in the United States. The selected faculty members observe under Dr. Marra at Northwestern Memorial Hospital in Chicago and Dr. Stetson at Stetson Powell Orthopedics in Burbank, Calif., for one week, gaining valuable clinical and surgical training that they can share and apply to their own practices.

"The observership is a great opportunity for Romanian surgeons to experience a well-organized healthcare system. It also enabled me to provide my patients with more information about their conditions and treatments," said Cristian Buescu, MD, who participated in the observership in 2015.

Future directions
The AAOS-Romania Shoulder Program tracks and reports on hospital quality-of-care outcomes and public health quality-of-life outcomes statistics. As a result, it has captured the interest and support of SOROT, the Romanian Ministry of Health, Northwestern University International Medicine Division, and Northwestern University School of Public Health.

As part of a research study conducted with Northwestern University, the AAOS-Romania Shoulder Program is working to validate the Oxford shoulder outcome score in Romania. Local faculty will collect outcomes data and plan to publish a research paper showing the value this educational intervention has on patient health/outcomes.

Qualitative research is also in progress. Local faculty were trained via Skype to conduct in-person interviews with participants. This process allowed for 50 interviews to be completed over a period of 2 days. The qualitative data will be analyzed to understand the motivation to participate in the program on both a faculty and participant level. The faculty expect to apply this information to the program design process.

"The AAOS-Romania Shoulder Program is providing us with a unique opportunity to more critically evaluate the multi-year international educational programs sponsored by the AAOS. Our aim is to provide a new model and course analysis that can be applicable to future international collaborations," explained Dr. Marra.

The AAOS-Romania Shoulder Program is meeting its goal to improve shoulder care in Romania and the surrounding regions, and will serve as a model for future programs.

Lisa Murphy is coordinator, international education programs at AAOS. She can be reached at murphy@aaos.org

2016 AAOS-Romania Shoulder Program Local Faculty

• Cristian-Tudor Buescu, MD (Romania)
• Ion Codorean, MD (Romania)  
• Semin Bećirbegović, MD (Bosnia)
• Cosmin Faur, MD, PhD (Romania) 
• Horia Haragus, MD, PhD (Romania) 
• Petru Razvan Melinte, MD, PhD (Romania) 
• Mihai Dan Roman, MD, PhD (Romania)

The AAOS-Romania Shoulder Program is supported by a grant from Zimmer Biomet.