It goes without saying: the road to a career as a Specialist Orthopaedic Surgeon is long and demanding.
That being said, the destination is still unquestionably rewarding.
Your journey begins with the successful completion of a Bachelor of Medicine and Bachelor of Surgery degree (abbreviated to the Latin MBBCh).
This is followed by mandatory internship and community service. These obligatory years of training/work are usually followed by hands-on experience as an junior Medical Officer (MO) in an Orthopaedic Surgery unit, in anticipation of successful entry into a Registrar training programme.
This article provides essential tips to help navigate you through these foundational stages.
Orthopaedic surgery is an expansive field, with training encompassing conditions affecting the entire body - top to toe. Picture: Authors Own
Understanding the South African Medical System
The nature of South Africa's national training programme for medical graduates is structured to provide comprehensive clinical exposure to junior medical doctors.
South African (SA) clinicians are widely considered second to none globally.
SA’s robust training programme is well-established and commands a long lived respect of – and demand for - South African trained doctors, worldwide.
The Internship Years
The Health Professionals Council of South Africa (HPCSA) allocates MBBCh graduates to accredited hospitals, giving them the opportunity to receive supervised clinical practice over the course of 24 months.
HPCSA-mandatory clinical rotations include:
- Internal Medicine
- General Surgery
- Obstetrics and Gynaecology
- Paediatrics
- Family Medicine (including Emergency Medicine, Primary Health Care clinics, etc)
- Orthopaedic Surgery
- Anaesthesia
- Psychiatry.
Clinical skills such as clinical examination and x-ray interpretation are important in basic clinical assessment and diagnosis . Pic: Author's Own
Internship bridges the gap between evidence-based theory and hands-on practice – solidifying medical knowledge while ensuring exposure to a wide range of common medical conditions.
This is crucial in the journey toward creating a well-rounded, safe and clinically competent doctor.
Strong clinical skills are developed through active participation in patient care, surgical procedures, ward rounds, morbidity and mortality meetings, interdisciplinary meetings and research.
Community Service
One year of Community Service follows internship, offering a unique opportunity to apply your medical knowledge independently in the service of the general public as an MO.
You'll encounter a diverse patient population and develop a deep understanding of the healthcare needs of your community.
While the challenges may be significant, it's essential to view this year as an opportunity to establish a strong foundation for your future career.
The best way to improve is by rereading and practice. Dr Maina applying a circular external fixator at a sawbone workshop. Picture: Authors Own
In the 12 months allocated to Community Service, resume your studies, working towards gaining competence in general surgical, trauma and orthopaedic diseases and procedures, while gaining certification in relevant clinical courses.
Advanced Trauma Life Support certification is essential in clinical as well as qualifying for and passing the Colleges of Medicine of South Africa (CMSA) examinations detailed below. Training backlogs and waiting lists are between several months to years long, and it is important to register early in anticipation of this lengthy wait.
Settling into a this period is also a good time to continue developing essential skills such as communication, leadership, and problem-solving.
Dr Maina in attendance at the South African Shoulder and Elbow Society Meeting in Cape Town. She is both a Fellow and Member of the Society. Picture: Authors Own
Preparing for Orthopaedic Registrar training
These foundational years and how you handle the adjustment to working in a clinical environment are crucial in shaping your career and preparing you for the rigors of orthopaedic training.
Entry to the orthopaedic registrar training programme is highly competitive, requiring meticulous preparation and consideration.
For this reason, it has become increasingly imperative to get an early start in building a strong professional, clinical and academic record from the outset.
Your capacity to work with multidisciplinary medical professionals and to lead a team cannot be understated.
Take the initiative and seek opportunities to gain exposure to surgery (orthopaedic, trauma and general surgery) and ICU through elective rotations, observerships, research, conferences and training workshops.
Learning is ever constant, but finding balance is just as important. Dr Maina standing next to a segment of the Berlin Wall at Ballhaus Biergarten after a long day of lectures and workshops in Berlin, Germany. Picture: Authors Own
How will I know if this is the right profession for me?
While career guidance counsellors can offer professional and individualised advice at any point in your career, I often get asked about my journey into orthopaedic surgery and my reasons for choosing the field.
My general advice to junior doctors seeking direction early in their careers, would be to take stock of one’s experiences in medicine at large as a profession and consider these questions:
- What gives you joy – both as a professional and private individual?
- Do you like being hands-on or working in an office/corporate space ?
- What types of personalities have you enjoyed interacting with in the field so far?
Aftercoomunity service, I started out in Epidemiology and Biostatistics. My brief exposure to a corporate/non clinical space helped me realise that actually I loved the job satisfaction to be found in the clinical environment.
I also feel that orthopaedic surgery attracts unique personalities whom I can personally relate to and work with. This is what drew me to the field.
In my opinion, orthopaedics is also refreshing in the diverse pathologies, procedures and patient profiles I see on a daily basis. This keeps me on my toes and constantly keeps the field interesting.
The field of orthopaedic surgery is expansive. Few other surgical disciplines are required to study, fundamentally understand and manage ailments from top to toe.
Orthopaedic surgery includes (but is not limited to):
trauma surgery
spine surgery
paediattric orthopaedic conditions
hand surgery
foot and ankle conditions
orthopaedic sepsis
bone cancer (primary or metastatic)
ligament/cartilage/tendon/bone pathologies
joint diseases/replacements
nerve injuries
soft tissue procedures (skin flaps, skin grafts, etc)
congenital and aquired disorders of mobility and function
care of those with genetic diseases, etc.
On top of this, the orthoapedic surgeon is required to work as part of a multidisciplinary team as well as understand and direct rehabilitation processes - liasing with Occupational Therapists, Physiotherapists, Biokineticists, Chiropractors, Personal Trainers, and so on.
An orthopaedic surgeon should also independently interpret radiologyand imaging studies - this requires an intrinsic understanding of radiology and radiography.
Dr Maina performing an assessment of a client's ACL using the pivot shift test. Picture: Authors Own
Mastering the Application Process – Becoming an Orthopaedic Surgery Registrar
As a prospective trainee, two crucial examinations hosted by the Colleges of Medicine of South Africa (CMSA) should be on your radar, and they would put you in good stead/be a requirement for your admission to the specialist training programme:
Fellowship of the College of Surgeons Primary assessments are the first wrtten examinations that all surgeons (irrespective of speciality) must write, covering principles in physiology, pathology, pharmacology, biochemistry, anatomy and molecular medicine
Fellowship of the College of Orthopaedic Surgeons of South Africa Intermediate examinations are non-clinical examinations that are require twelve months of orthopaedic training, three months in general surgery and three months in ICU to write
Specialist training posts are generally open for intake twice a year. These limited openings are often oversubscribed with multiple interviewees accepted for each open position.
Simply put, you need to find a way to stand out from the crowd.
This includes, having CMSA 'Primaries' and 'Intermediates' under your belt, demonstrable experience in the field (using a logbook exemplifying first-hand competence in common orthopaedic surgical procedures), engagement in research, attendance at orthopaedic meetings/training, etc.
Before sending in your application, reach out to the various faculties/registrars (Reg's) in the training programme and do some research. Gain an understanding of the work culture, focus, training, advancement opportunities and mentorship programs available at different training programmes countrywide.
Craft a concise (but brief), professional and compelling Curriculum Vitae (CV) that highlights your academic achievements, clinical experience, research contributions, and personal qualities.
Prepare for interviews by reviewing common orthopaedic conditions. This will help showcase your academic focus and engagement with Orthopaedic surgery. A good understanding of public healthcare principles in a South African context is also important.
Arrive for your job interview(s) early, dress appropriately, make eye contact and prepare relevant questions to ask your interview panel.
Donning a Flyte suit helmet before scrubbing in for joint replacement. Picture: Authors Own
Your Masters Degree and Qualifying As a Specialist Orthopaedic Surgeon
Congratulations on your acceptance to the Reg training programme!
During your time as a Reg, you will be expected to complete and submit a Masters research project.
The best research project topic is something you personally have interest in within the discipline. You will need two supervisors for the project and I would recommend monthly meetings with your supervisor(s) to ensure consistent progress and timeous completion.
The process of conceputalising, writing up, submiting your proposal to the Ethics Committee, data collection, statistical analysis and final writeup is arduous and time-consuming, but should be commenced early as it is a necessary step towards qualifying for your final orthopaedic examinations.
'Finals' are a two-part assessment conducted at the completion of a four year (minimum) specialist training programme. Written final exams are held over the course of three days. Thereafter, successful candidates are invited to oral/clinical Finals.
Orthopaedic Surgery is an expansive field. Dr Maina explaining the use and function of Ponseti boots (TM) for babies. Picture: Authors Own
“Physician heal thyself!” - Maintaining Work-Life Balance
Be kind to yourself. Focus on expanding your adaptability and resilience. Attributes that will certainly help navigate the physically and mentally demanding challenges of orthopaedic surgery.
Overall, it is still important that within one's training years, that you continue to maintain a balanced lifestyle.
The hours are long, the work is demanding. While job satisfaction in orthopaedic surgery is generally amongst the highest in the medical professions, a career of service always demands significant sacrifices.
This demanding nature of clinical practice can lead to burnout, dissatisfaction and depression among other problems.
It is imperative to build and maintain solid boundaries between work and home. At home, make sure to tap into activities that energise, restore and lift your spirits,
Establishing a sounding board (a senior medical colleague, a psychologist, etc.) with whom one can regularly debrief and discuss personal stressors among other issues, is vital.
Lastly, eat well and drink well (and mindfully) and get sufficient sleep.
Dr Maina on a specialist surgeon visitation hosted by Dr Luc Kerboull at Clinique Arago, Paris, France. Dr Kerboull is son of the famed Philippe Kerboull - originator of the Kerboull Angle, a predictor of head collapse in Avascular Necrosis of the femur. Pic: Author's Own
Conclusion
Becoming a medical specialist is a whirlwind of growth, learning and challenges: from establishing your professional identity and interests, manifesting your independence as an adult, developing essential leadership and/or communication skills - a lot happens in those first years after attaining ones MBBCh and narrowing one's focus to a specific field.
Establish early a balanced lifestyle and build within yourself well-rounded individual.
Embrace the challenges and never stop learning!
Dr Anne Maina
Specialist Orthopaedic surgeon
MBBCh (Wits), FC Orth (SA), MMed Ortho (Wits) CIME
"Stay curious, keep learning and keep growing. Always strive to be more interested than interesting" - Jane Fonda
References:
1. Ramoolla B, Van der Haar G, Luke A, King R, Jacob N, Luke B. Medical internship training in South Africa: Reflections on the new training model 2020-2021. South African Medical Journal. 2023 May 1;113(5):1195-8.
2. Colleges of Medicine of South Africa. (2024). CMSA. Accessed: 18 Aug 2024. https://cmsa.co.za/
3. Health Professions Council of South Africa. (2024). HPCSA. Accessed: 18 Aug 2024 https://www.hpcsa.co.za/
4. South African Medical Association.(2024). SAMA. Accessed: 18 Aug 2024. https://www.samedical.org/
5. South African Orthopaedic Association. (2020) SAOA. Accessed: 18 Aug 2024. https://saoa.org.za/about-the-saoa/
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