Orthopaedic Surgical Training in Nicaragua: Observations and Recommendations

In July 2007 Gabriel Martinez-Diaz and Dr. Harry Jergesen visited two Orthopaedic training sites in Managua and Leon, Nicaragua to gather information about the current status of the various training programs and to learn about changes in training that are presently being proposed. The overall goal was to identify strategies with the hospital administrators and clinical faculty that might increase the effectiveness of efforts to create sustainable improvements in orthopaedic education and musculoskeletal care in Nicaragua.

Gabriel and Dr. Jergesen gathered information by speaking to groups of orthopaedic teachers and residents, both inside and outside the hospital setting. They also talked to the Dean of the Faculty of Medicine in La Universidad National Autónoma de Nicaragua (UNAN) Managua, Dr. Freddy Meynard, and, later during their visit, to a representative of the Dean of the Faculty of Medicine of UNAN-Leon, Dr. Rudolfo Peña. Finally, they met with the President and Board of Directors of the Asociación Nicaragüense de Ortopedia y Traumatologia (ANOT), the Nicaraguan national orthopaedic association. These interchanges allowed them to more fully understand the current status and most significant challenges that face orthopaedists-in-training in this resource-constrained country.

The meetings resulted in several recommendations that the collaborators and IGOT felt would set the stage for improved orthopaedic education, promote more productive interchanges with outside groups, and provide a clear understanding of the areas of musculoskeletal care that most need to be addressed from a public health point of view.

The following are the recommendations that resulted from this observational Research Initiative:

1) Orthopaedic training in UNAN should be four years

2) A uniform resident training curriculum and educational objectives should be established for all training sites.

3) A collaborative resident rotation schedule should be established between UNAN hospitals to insure exposure of each resident to all critical areas of orthopaedic training. To add to this, combined conferences and educational rounds and lectures should be scheduled to bring residents and teachers from the various hospitals closer together in their training.

4) MINSA (Ministerio de Salud) and UNAN should provide resources to improve the knowledge base and mentoring skills of orthopaedic educators in each of the training hospitals.

5) MINSA and UNAN should continue to support appropriate outside projects designed to improve the delivery of orthopaedic care in all of the UNAN training hospitals. Until government funding becomes available in the future, this may well involve coordinating efforts from outside organizations to assist in improving instruction, in documenting areas of need to justify funding from foreign sources, and in providing material support where it will do the most good. It was sensed, in widespread agreement that sporadic short-term missions from overseas to date have not provided the sustained, long-term benefit and stimulus for improvement that is needed. The timing of missions is inconsistent, the degree of educational interchange is variable, and the non-uniform distribution of the visits leaves some locations without access to outside contact. It is important to ensure that these efforts are evenly distributed between the participating UNAN training hospitals. As an organization separate from the individual training sites, ANOT, in collaboration with the training site directors, may well be the ideal entity to broker overseas interchange agreements to ensure that they achieve maximum impact and fair distribution.

6) Partnership agreements with outside educational institutions, such as IGOT, OO or university-based orthopaedic departments, should be encouraged in order to promote the educational agendas in the public teaching hospitals.

7) It is suggested that the elected leaders of ANOT, in conjunction with MINSA and UNAN, help to organize new collaborative efforts between the training sites. As emphasized above, it is suggested that ANOT take a lead role in directing the assistance efforts of foreign organizations to ensure that they are more evenly distributed between the training hospitals and that they provide educational support of the type that is most beneficial to their patients, residents and staffs.