Nationwide changes in the organisation of specialist medical training present a challenge to surgical trainees in terms of exposure to an adequate case load, the acquisition of practical experience and therefore also of judgement and decision-making. When accompanied by accredited trainers exposure to practice in the developing world offers trainees the opportunity to enhance their clinical exposure as well as skills in communication, teaching, management and leadership. This paper analyses the training value for orthopaedic trainees of a novel orthopaedic project undertaken in Kenya in February 2009 utilising an entire UK orthopaedic team. The first Kenya Orthopaedic Project (KOP) was organised by an orthopaedic trainee and took place at Nanyuki District General Hospital in February 2009. Kenya does not have the luxury of a national health service and patients must pay for any clinics or surgery. The cost of orthopaedic surgery in this environment is prohibitive and many fractures go untreated, as do other common pathologies such as severe osteoarthritis and osteomyelitis. The UK team undertaking the project included two accredited consultant orthopaedic surgeons and an orthopaedic trainee. Clinics, surgery and teaching sessions were performed for one week with the aim of relieving the sheer volume of orthopaedic cases and to provide those impoverished patients with treatment they would not otherwise receive. Data was taken from elogbook to analyse the average number of cases performed by an orthopaedic ST3 in one week, and a survey was sent to all Southwest trainees (n=25) for information on how many competencies and work placed based assessments were completed in one week. Daily challenges of health care budgeting, negotiating, organisational and intercultural communication skills are not often encountered by UK orthopaedic trainees, and bring with them a realisation of the wider picture of health care economics and appreciation of the benefits of a National Health Service. The results showed that in one week during KOP over seventy patients were seen in clinic and eighteen operations performed. Of the 18 operations performed the orthopaedic trainee assisted in 15 of these operations and performed 3 under supervision. An average week log book entry for ST3 trainees, taken from elogbook statistics, contains six elective and three trauma operations. The figures from one week Kenya Orthopaedic Project double these operative numbers. Six workplace based assessments were completed in one week on the project, significantly more than an average of 0.16 per week in UK. (p=0.0003). In conclusion Kenya Orthopaedic Projects offer a unique experience for orthopaedic trainees and all members of the multidisciplinary team. Trainees are offered the opportunity to put into practice managerial, teaching, organisational and communication skills as well as the chance to see and treat pathologies that would not be encountered in the UK. The experience of operating in third world conditions with minimal equipment available, communicating with patients and theatre staff from a different culture whilst ensuring all possible western world safety measures are adhered to offers a wholly challenging and valuable perspective to an orthopaedic trainee. Both operative experience and workplace based assessments statistically surpassed that of an average week of a UK trainee. We can therefore conclude that a week’s orthopaedic experience in a third world country is not only beneficial to the patients but offers excellent training opportunities in all aspects of the delivery of health care and makes a positive contribution to orthopaedic training.
Patient satisfaction is a driving force behind setting up and developing day case procedures. Ten months ago a service for day surgery SCARF procedures was set up in Torbay day surgery unit. We analysed patient pre and post operative pain scores and patient satisfaction scores in respect to pain, appearance and overall satisfaction. A questionnaire was sent to all sixty patients who had undergone a SCARF osteotomy in day surgery. Outcomes assessed were: reason for SCARF osteotomy; adequate preoperative information; pain scores pre and post operatively; satisfaction scores and admission rates. 53 patients responded (88% response rate). 79% of patients had their operation for pain, 19% for appearance and footwear, and 2% for function of their foot. 100% of patients were given adequate information by the surgeon preoperatively and 27% also used other sources for information. 62% of patients scored 6 or more on a linear pain score preoperatively. 85% of patients have a current pain score of 0 or 1. 87% were highly satisfied (scoring 9 or 10 on linear scale) with the outcome regarding their pain, 83% highly satisfied with appearance and 72% highly satisfied with function despite the questionnaire being completed less than one year post surgery. 83% of patients were highly satisfied with the overall procedure and 91% said they would have a SCARF as a day case procedure again. 9 patients were admitted, 3 due to living alone, 3 for wound problems and 3 for post anaesthetic problems including pain, nausea and vomiting. From these figures we concluded that SCARF osteotomy in day surgery is a successful, feasible and worthwhile undertaking in our unit. We used the questionnaires and results to further analyse our service and we have made modifications to improve it. We have now put in place a dedicated anaesthetist with an interest in foot and ankle blocks, as well as a comprehensive post operative analgesic regime and a stringent day surgery protocol. We now run a prospective questionnaire from clinic, including AAOFAS scores, to continue analysis of our service. With these changes in place we would like to see our satisfaction scores rising towards 100%.
