AIM: To compare the trauma experience gained by a trainee at a United Kingdom major trauma centre and a secondary level hospital in South Africa.

METHODS: A profile of inpatient trauma cases during a five-week period in Addenbrooke’s Hospital, Cambridge and Somerset Hospital, Cape Town was created. This was achieved by recording various parameters for each patient admitted including age, gender, injury, mechanism of injury and postal/area code. This, together with details of the departments themselves, allows a comparison of the amount and variety of orthopaedic trauma cases experienced by an individual trainee in each setting.

RESULTS: The trauma profiles differed significantly. Patients in Cape Town were younger and more likely to be male. In the young, injury in Cape Town was more likely to occur due to assault or being struck by a vehicle, whilst patients in Cambridge were more likely to be injured whilst in a vehicle or in high energy falls. In older patients, trauma at both centres was almost exclusively due to mechanical falls. In a given age group, injuries at the two centres were similar, however the majority of patients admitted to Addenbrooke’s were elderly, resulting in less variation in the overall injury profile.

CONCLUSION: The trauma profile of a major trauma centre in the United Kingdom is less varied than that of a South African secondary centre, with significantly fewer cases per surgeon. This suggests a more varied training experience in the developing world with a greater caseload.

Injury secondary to trauma is a major public health issue. It is a leading cause of death world wide, with road traffic accidents alone accounting for 1.2 million deaths per year[1]. By 2020, musculoskeletal injury will account for 20% of all the world’s disability-adjusted life years. The vast majority of this burden lies with the developing world with low and middle-income countries entering the third phase of epidemiologic transition. This entails an increase in the average life expectancy and a consequent exposure of the population to the so-called man-made diseases[2-4]. Despite this growing burden, orthopaedic care in the developing world remains scarce when compared with developed countries, with only one in three people provided for[5].

This disparity in demand and supply of orthopaedic care has implications for orthopaedic training across the globe. This study profiled the orthopaedic trauma admissions at two centres in contrasting settings; one a major trauma centre in Cambridge, United Kingdom, the other a secondary level centre in Cape Town, South Africa. These two counties exemplify the difference in disease burden, with injury accounting for 2.7% and 9% of deaths respectively[6,7]. A comparison would therefore make it possible to quantify how this increased burden in the developing world influences the experience of the orthopaedic trainee in South Africa in comparison with the trainee in the United Kingdom.

The aim of the study, therefore, was to compare, contrast and objectively quantify the trauma admissions that a trainee would be exposed to whilst based in Cambridge, United Kingdom and in Cape Town, South Africa. This in turn would have implications for those intending to train in trauma surgery.

The trauma profile at Addenbrooke’s hospital, Cambridge was markedly different to that of New Somerset Hospital, Cape Town. Patients at New Somerset were younger and more likely to be male. In both centres, there was a similar injury pattern in any given age group, with a notably broader range of injury in younger patients. However, the patients admitted to New Somerset Hospital were of lower average age, resulting in a much more varied overall injury profile at this centre.

Patients in the younger age groups admitted to New Somerset Hospital were more likely to be injured by interpersonal means or following pedestrian motor vehicle accidents than patients in the same age group admitted to Addenbrooke’s Hospital, who were more likely to be injured following an in - cMVA or a high energy fall. These differences reflect the hospitals and their settings; Addenbrooke’s Hospital is a level one trauma centre and is therefore specifically tasked with treating more high energy trauma injuries such as those sustained during in-car motor vehicle accidents or high energy falls. Conversely, new Somerset Hospital serves an area with high rates of interpersonal crime, leading to more injuries sustained by these mechanisms. In the elderly, trauma at both centres was almost exclusively due to mechanical falls with the majority of injuries being fragility fractures.

The geographical distribution of cases at the two centres was comparable, with a similar average distance and range of distances between patient address and hospital. The distances between patient address and Addenbrooke’s Hospital were more normally distributed than those at New Somerset Hospital. This is in keeping with the role of Addenbrooke’s Hospital as a major trauma centre, taking referrals from all parts of the East of England. The distribution of distances between patient address and New Somerset Hospital showed a clear bimodal distribution. These two groups reflect the two distinct areas served by the hospital; the first being western and central Cape Town and the second corresponding to patients admitted from outreach clinics in rural communities far from the hospital (Figure 5).

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Figure 5 A composite map, to scale, showing the geographical location of trauma in Cambridge (left) and Cape Town (right).

In order to fully analyse the experience of a trainee, these trauma profiles must be placed in the context of the two centres. Although Addenbrooke’s Hospital admitted more than twice the number of patients than New Somerset Hospital, it employs a significantly larger workforce, with a total of thirty-four surgeons (eighteen trainees, sixteen consultants) to New Somerset’s four (two trainees, one full-time consultant and one part-time consultant). This imbalance in the number of surgeons results in a much greater trauma caseload for the trainee in Cape Town, South Africa. This, together with the more varied injury profile at New Somerset Hospital, enables the trainee to gain wider experience in the management of orthopaedic trauma.

Whilst caseload is an important aspect of surgical training, it is not the sole determinant of its quality. The training programmes in both countries follow the traditional apprenticeship model and are largely comparable, with some subtle differences which should be understood when comparing the experience gained by a trainee. In South Africa, orthopaedic training is undertaken following a two year internship and community service year. Training takes place at one of nine accredited universities, two of which are accredited for the first two years of the training programme only. This is similar to the structure of training in the United Kingdom which takes place in one of twelve regions in England, Wales and Northern Ireland (Scotland has a separate training structure). Each region contains at least one teaching hospital linked to a university. United Kingdom medical graduates undertake a two-year foundation training programme analogous to that of the South African internship, however there is no equivalent to the community service year in the United Kingdom. Instead, trainees must complete the two-year core surgical training programme before applying for specialty training in orthopaedics.

Both South African and United Kingdom orthopaedic specialty training programmes typically last for five years, and require the completion of various examinations in order to progress. In South Africa, training works on the basis of three levels of study. The first level is assessed with the primary examination, which focuses on basic surgical sciences such as pathology and anatomy. The second level of study concludes with the orthopaedic intermediate examination, which focuses on the clinical aspects of surgery, with a focus on orthopaedics. Enrollment in the intermediate examination requires candidates to have eighteen months of experience in one of the aforementioned university hospitals, including intensive care and trauma experience. The final part of training involves six month rotations through the various orthopaedic sub-specialties with attachment to a consultant for each rotation. During this part of training, trainees must publish at least one research article. Upon completion of three years of rotations, trainees may register for the final examinations, the fellowship of the college of orthopaedic surgeons of South Africa, meaning a surgeon can be fully qualified eight years after graduation from medical school.

Orthopaedic specialty training in the United Kingdom follows a similar pattern, though trainees must attain Membership of the Royal College of Surgeons (MRCS) prior to the commencement of specialist training. This involves passing two examinations; the first a written exam with a focus on basic surgical sciences and principles of surgery in general and the second an objective structured clinical examination which focuses on applied surgical sciences with practical and communication skills. In this regard, the MRCS is comparable to a combination of the primary and intermediate examinations in South Africa, though it lacks specificity to orthopaedics. In a similar fashion to South Africa, the training programme lasts for five years and involves six month rotations through sub-specialties with attachment to a consultant. Like South Africa, trainees take the Fellowship of the Royal College of Surgeons after three or four years of specialty training. Trainees are expected to regularly partake in research and quality improvement. Overall, trainees can be expected to complete training nine to ten years post-graduation[8,9].

Both training programmes have a set of competencies which are expected to be achieved at the completion of training. This essentially requires trainees to be competent in a range of orthopaedic procedures, with competency defined as the completion of a defined number of cases.

The apprenticeship nature of surgical training means much depends on the quality of the mentor, meaning there will always be natural variation in the quality of training. However, the similarity of the training programmes in these two countries places emphasis on the quantity and type of orthopaedic trauma experienced by a trainee. This study shows trainees at Addenbrooke’s Hospital experience fewer cases than their counterparts at New Somerset Hospital, and the cases they do experience are less varied.

To this end, the study highlights the potential benefits of establishing training programmes that combines the structure of a United Kingdom major trauma centre with the volume and variation provided by hospitals in the developing world. Currently, trainees in the United Kingdom are able to apply to their regional training body for out of programme clinical experience (OOPE), which can take the form of work in the developing world. Whilst studies such as ours highlight the potential benefits this would hold for the trainee, time out of programme does not often gain approval for clinical training and thus can delay career progression, making it an unpopular choice amongst trainees.

An alternative to OOPE is an approved fellowship abroad. Several studies have shown the benefits of establishing synergistic partnerships between hospitals in the developing and developed worlds, whereby trainees from each centre swap roles in order to broaden their surgical experience[10,11]. We believe that expanding the number and variety of such fellowships will help surgeons worldwide to establish best practices and increase the standard of trauma care in a time when traumatic injury is increasing at an alarming rate.