ABC Fellowship – A Trip of a Lifetime 

The Fellowship

The American, British, Canadian (ABC) Fellowship is the most prestigious travelling fellowship in orthopaedics. It was launched in 1947 by Robert Harris, the then president of the American Orthopaedic Association (AmOA), who proposed that young consultant surgeons from the UK, visit North American centres to establish links between the nations, and promote development and leadership in orthopaedics.

The AmOA mission is: to identify, develop, engage and recognise leadership to further the art and science of orthopaedics’. This is also the philosophy of the fellowship.

Selection is by application and candidates have to be under 45 years old and have a significant academic record. Six weeks away from a busy public and private orthopaedic practice and family life is a significant commitment, but the fellowship is a way of stimulating an established consultant practice and, perhaps also, a time to reflect on our career paths.

The Trip

The general basic formula of the fellowship program was to start the day with an academic session, where we would present our research to the clinical and academic units. The hosts would often then present their own latest work – much of it groundbreaking. We would then either visit the research facilities, laboratories, surgical skills facilities, or go into the operating theatres. The late afternoon would often be spent visiting local sporting, historical or cultural sites and in the evenings we would attend social events or formal dinners where we would meet the faculty and clinicians and often their spouses.

The tour started in London, UK, where the seven fellows met at the offices of The British Editorial Society of Bone & Joint Surgery, publishers of The Bone & Joint Journal (Formerly JBJS Br).

The editorial team gave a sequence of presentations outlining the review and editorial practices of the journal, together with reflections on the role of the journal (and its new companion publications: Bone & Joint Research and Bone & Joint 360).

From London, UK we headed to London, Ontario, Canada (a very well known academic orthopaedic centre). We learnt about the Canadian health care system and about research into compartment syndrome, muscle repair, and joint replacement follow-up. We tried state-of-the-art surgical simulators and we recognised their patient safety importance with reduced numbers of procedures being performed during modern training. This is definitely a way forward for future training in Australia, as clinical exposure during training becomes more restricted. The Canadian’s are well advanced in competency-based training.

We then headed north to the Mayo clinic in Minnesota – one of the most prestigious hospitals in the USA which, employs more than 30,000 people in a town of only 100,000 – and then onto Minneapolis where we visited our relevant subspecialties for seminars and theatre sessions. The paediatric research dissecting out the indications for different procedures in patients with cerebral palsy was particularly impressive. We visited one elective unit where the patients were discharged to a Hilton hotel rather than keeping them in hospital!

The next stop was Chicago. Here we visited five different centres – Loyola, Rush, North Western, Cook County and University of Chicago (UC) – which showed the variation in health care across the private, university and public systems. UC was highly academic, and had a strong community and service ethos. Rush was the ultimate private unit, with immaculate facilities (particularly their cadaver facilities which were easily accessible for the trainees to operate). Research at Rush was into implant design and testing, and there was a lot of interest in our experience of metal bearings. Cook County was the public hospital made famous in ER.

The University of Iowa, in Iowa City, was a highly integrated academic clinical centre. It has many past ABC fellows and an amazing history of contributions to orthopaedic practice, including the development of the Ponseti technique. We learnt about clubfoot, cartilage injury and joint replacement follow up. Stu Weinstein gave us two pivotal lectures – one on the challenges faced by the US healthcare systems, and another on how to run a large scale randomised clinical trial, with reference to the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST).

Next was Nashville, where we had a great time in small group sessions with the faculty (trainers) and residents (registrars). We were particularly impressed by the work of the bone biology group in the Schoenecker laboratory. Later we visited the Jack Daniel’s distillery, which is in a county where it is actually illegal to drink alcohol!

We then moved onto the Campbell Clinic in Memphis where the premier textbook in orthopaedics is produced. It was pleasing to see that, like everywhere else, the preparation involved reams of papers stacked on the floor.

Cleveland, Ohio is the home of the Cleveland clinic – famed for its quality control and outcome assessment work and has been very innovative with patient-driven care and encourages its best clinicians to take up managerial roles. This gets the very best people in charge of hospital units. We stayed at the homes of the faculty in Cleveland and this gave us a unique insight into their values and views. Friendships were made here and we learnt from the world experts on avascular necrosis, revision knee replacement surgery, thromboprophylaxis and Perthes.

The final clinical stop was in Pittsburgh with the energetic Freddie Fu. He is a real celebrity surgeon in Pittsburgh and chairs an impressive unit. This hospital group (UPMC) turns over 10.5 billion dollars a year, and facilities for research are incredible. UPMC has an enviable record in splicing together clinical and basic sciences and we were particularly impressed by Johhny Huand’s stem cell laboratory.

We ended our tour at the annual American Orthopaedic Association meeting in Washington DC where we caught up with several of the surgeons that we had met earlier. The focus was on training and leadership. It was a critical time in the US for health care politics, with  President Obama’s health care bill causing political polarisation in the medical community. The cost of health care in the US is 18% of gross domestic product, and this is unsustainable. Although estimates vary, around 20% of the population don’t have access to healthcare, aside of emergencies.

Learnings and Insights

We found that there is virtually no teaching of musculoskeletal medicine to US undergraduates in most of the centres. A degree is completed before going to medical school, with training normally lasting four years – accruing a debt at graduation averaging over $210,000. Once they enter specialist training, the residents (registrars) are taken good care of and the relationship between trainers and trainees is close with effective mentoring over their five-year training scheme. There are occasional six-year programs, which includes a year of research funded by the local institutions.

Trainees and faculty alike have a strong sense of identity with their program and brand is important. They stay in one unit, which gives them much more contact with their trainers – resulting in a good training over a relatively short time period. Hours are long (up to 80 a week), and it is unclear how new legislation on working hours will impact on this training in the future. Furthermore, the system for both billing and litigation purposes doesn’t allow for trainees being recorded as doing the surgery, and thus, it’s very difficult to quantify when actual training occurs from the logbook data.

Funding of the big units that we visited is very different to that in our systems. They are definitely businesses, and if they don’t make money, they lose their best doctors and close.

Measures of quality are important, advertising is important, and competition is important. Coding is the central key to recouping costs from the government and insurance companies, and accuracy of this is paramount. This is also their basis for research data collection and surgeon appraisal and payment. Research is an important way of defining and advertising a unit. This attracts very large grants from bodies such as the National Institute for Health as well as enormous endowments. The culture of philanthropy is widespread – none of the ABC fellows had experienced that in their home countries.

Most of the units have access to cadavers and simulation. Quite a few of the units seem to run successful simulation prior to the residents operating on patients. London, Ontario and Pittsburg showed us their arthroscopy simulators, which had remarkably realistic haptics. Most centres had surgical skills labs where basic to complex surgical skills could be practiced as well as non-technical skills. We also saw some superb cadaveric surgery facilities in many centres.

It was clear on the trip that the actual practice of trauma and orthopaedics is technically the same in North America, England and Australia, although we have different approaches to some issues such as implant choice. One concern that is often voiced of the US system is that the majority of orthopaedic care (80%) is carried out in the community by ‘low volume’ generalist surgeons, who have variable collegiate back-up and quality control. This is perhaps partly why the revision rate for joint replacement in the US is much higher than European and Australian registries. Hence, one of our hotter topics for discussion related to how we measure quality and performance and maintain standards in this environment. The joint registries in Australia, New Zealand and England and Wales are clearly one way towards this goal and are very much desired by the big US centers.

An Unparalleled Opportunity

We felt greatly honored to travel as ABC fellows and the list of highly esteemed former fellows demonstrates what company we are in and what is expected of us in the future.

The effort our hosts made to ensure that we were well looked after ensured a trip of a lifetime. We really felt like we had become part of an exclusive club that will reap benefits for the rest of our lives both in and outside of work.

Nothing could prepare us for the opportunity to meet the real people behind the big names in orthopaedics. This fellowship put us in a unique position to meet many of the world’s greatest orthopaedic surgeons and researchers and there is no other way to get this kind of exposure to such influential people and at such an intimate level.

The management, quality, funding and organisational skills learnt during the fellowship will no doubt prove invaluable in future management roles.

We all face similar problems, with limited funding of health care, maintenance of standards, and support for leadership and academic orthopaedics. The ABC Fellowship is an unparalleled opportunity to help promote and improve our profession across the globe.