An Out Of Programme Experience (OOPE) to gain clinical experience

...currently lacking in the NHS Trauma and Orthopaedic Higher Specialty Training System 

By Ullas Jayaraju

I’m an orthopaedic higher specialty trainee currently working in the NHS and I recently decided to take an Out Of Programme Experience (OOPE) between my ST4 and ST5 training years.  I’d like to share my fellowship experience from Ganga Hospital, India. 

The NHS training programme, although structured, was proving slow to restart following the COVID-19 pandemic and the effect has been, as expected, long-lasting.  Nevertheless, the demands on surgical training remain, with surgical trainees still requiring to cover 300 cases per year, 40 work-based assessments (WBAs), a completed audit cycle, research and publications.  The new training curriculum doesn't necessitate that one finishes surgical training within a particular time frame.  However, to achieve these stated goals, one should ensure that experience and training is optimised during the training period.  On completion of training, one is expected to be an Orthopaedic Consultant with the ability to perform independent clinical practice. Unfortunately, within the NHS training programme, the opportunity for high volume elective orthopaedic cases is, at present, limited.  This is in part due to the lack of elective centres, which has been highlighted by the COVID-19 pandemic.  It must also be stated that trauma cases are backlogged, with cases pending and waiting days at a time, due to reductions in operating theatre time and lack of key theatre staff.  Given the NHS runs at full capacity, there is little room for adaptation and restructuring to increase workload/improve workload efficiency on a day-to-day basis.      

The reasons for my OOPE were multifold.  Surgery is a craft specialty, requiring time and experience in the operating room to improve one's skills.  Given the reduction in workload within the NHS, I wanted to gain further experience in orthopaedic surgery in a high volume centre outside the UK NHS system.  Working within such healthcare systems will expose one to high volume, unique and rare cases.  As a result, I chose to undertake a fellowship abroad, in Ganga Hospital, India.

Ganga Hospital is situated in Coimbatore, Tamil Nadu, India. Coimbatore is well-known for being an area with high levels of medical tourism, with people traveling from all around India and internationally for medical care and treatment.  Ganga is a private hospital, first established in 1978 with 17 beds.  The hospital now has a capacity of 650 beds, performing around 26,000 operations per year.  A centre of excellence and widely regarded as one of the best orthoplastics centres in India, Ganga Hospital has two large imposing buildings – Block A and Block B – where emergency surgery and elective surgery are performed respectively.

I started my fellowship in Block B, where I met Prof Rajasekaran (Chairman of the Orthopaedic Department) and Dr Balavenkat Subramanian (Head of Anaesthetics and Education Lead).  I subsequently undertook my six-week fellowship in orthopaedic sports surgery with Dr Sundarajan (Head of Orthopaedic Sports Surgery) and arthroplasty surgery with Dr Rajkumar and Dr Dhanasekra.

On my first day, I walked into the Operating Theatre (OT) Complex, where there were 10 elective theatres running simultaneously.  Three sports surgery theatres, four arthroplasty surgery theatres and three spines surgery theatres.  I observed the sports surgery team complete 15 operations in one day.  These included arthroscopic anterior cruciate ligament (ACL) reconstructions, arthroscopic meniscal repairs, arthroscopic rotator cuff repairs and arthroscopic Bankart’s repairs.  The OT started at 7:15am and finished by 3pm.  The efficiency of the OT system was remarkable, with no delay in commencement of cases.  Overall, I was able to observe the following cases: arthroscopic ACL and posterior cruciate ligament (PCL) reconstructions, menisci repairs (including buckle-handle repairs, root repairs and centralisations), arthroscopic Bankart repairs, posterolateral corner (PLC) injuries, plus arthroscopic labral repairs.

Each operating theatre was exceptionally well-staffed, with one consultant orthopaedic surgeon, one or two orthopaedic fellows, one consultant anaesthetist, one anaesthetic fellow, two scrub nurses and two theatre technicians.  This ensured theatres ran to very accurate timings, with the workload evenly distributed among the ample theatre staff.  Another reason for each theatre being very well-organised was due to the skill level and experience of the consultant orthopaedic surgeons, consultant anaesthetists and the respective scrub teams.  The high volume of cases means surgeons are constantly gaining experience, finding new methods of improving their skills, as well as optimising surgical treatments and efficiency.

Another vital aspect of the surgical team are the scrub nurses.  The scrub team trains with a specific surgeon’s team for around one year, prior to formally assisting in cases.  This means the scrub team knows exactly what the surgeon needs and when it is required.  Most often, the surgeon would not even turn around for the required surgical instrument – it would be ready in his outplaced hand, making it an extremely smooth and efficient process.

Moving onto arthroplasty, I assisted and observed operative cases helmed by Dr Rajkumar and Dr Dhanasekara.  Annually, between the two arthroplasty teams, around 2,000 total hip and knee replacements are performed.  An outstanding aspect of the Ganga orthopaedic system was the fact that elective patient waiting times were almost non-existent.  To put this into context, both the sports and arthroplasty team would have two elective clinics each week and if a patient required operative intervention, they would be placed onto the next day's operating list.  The patient would be admitted onto the ward, followed by a swift review by the anaesthetic team and optimised for theatre.  The perioperative care provided at Ganga Hospital must be highlighted and is part of the reason for efficient case flow. Ganga is a very well-established centre for regional anaesthesia and many patients underwent spinal/regional anaesthesia –meaning that post-operative analgesia and post-operative recovery was optimised.  Moreover, the regional anaesthesia ensured no delay in patients entering the OT.  For all sports and arthroplasty patients, there is a structured physiotherapy and follow-up plan post-operatively. 

Ganga Hospital has numerous advantages for incoming fellows from abroad.  The sheer volume of cases alone provides an experience which is unmatched within the NHS system.  Moreover, the complexity and pathology of cases is another unique aspect of the area.  The high volume also allows doctors the opportunity for high-quality research projects.  My primary aim during this fellowship was to gain clinical case experience, in the OT and outpatient clinic settings.  Although I was not able to perform cases independently, I was able to assist which was a hugely valuable experience.  During my six weeks, I observed and assisted in a total of 117 operative cases, once again highlighting the massive operating capacity.  If one were to undertake a six-month or one year fellowship, I believe this could make up for the low number of cases being undertaken in the NHS. A trainee can gain experience, operative numbers, WBAs and research if the institution provides the infrastructure.  This would provide an opportunity for trainees to count their OOPE time into their training schedule.  I believe this could be an exciting chance for trainees to explore the world's healthcare systems, while continuing their training