Clinical Fellowship in Paediatric Orthopaedics

I About The Programme
II Assessment and Evaluation
III Target Audience and Eligibility Requirements
IV Other Information

I About The Programme

Name of Programme

Clinical Fellowship in Paediatric Orthopaedics

Overview

KK Women’s and Children’s Hospital (KKH) is a Joint Commission International (JCI)- accredited Academic Medical Centre (AMC) affiliated to Duke-NUS Medical School . The Department of Orthopaedic Surgery at KKH is the only fully dedicated paediatric orthopaedic department in the country. To allow for a fertile environment for learning, which is ideal for training at the Fellowship level, the department hosts learners from several different academic institutions at different levels:

• Undergraduates: Yong Loo Lin School of Medicine, Lee Kong Chian School of Medicine
• Graduates: Duke-NUS Medical School
• Postgraduates: Residents from the ACGM-I accredited Singhealth Residency and the NHG Residency Programme and the College of Surgeons Edinburgh-accredited Seamless Trainee leading to the FRCS (Ortho)

For more information on the Department of Orthopaedic Surgery, click here.

Aim of Programme

To train a general orthopaedic surgeon who has an interest in paediatric orthopaedics as a career in their parent country or institution. To this end, preference is given to fellows who come from regions in great need for specialised paediatric orthopaedic care but with paucity of training in that area.

Duration of Programme

6 months

Number of Training Places

1 Fellow per 6-month block with intakes in January, April, July and October

Learning Outcomes

At the end of the rotation, the Fellow should be proficient with the management of elective and emergency paediatric orthopaedic conditions including:

• competence in diagnostic workup;
• competence in assisting in surgical procedures;
• competence in the management of symptoms and surgical care in paediatric orthopaedic conditions.
  

Content Areas

The teaching activities include:

• weekly combined structured expert case discussion in KKH and the National University Hospital (NUH);
• didactic teaching as specified by the Singhealth Residency Programme for Paediatric Orthopaedics;
• monthly journal readings and critique;
• daily X-ray rounds;
• monthly ortho-radiology conference;
• weekly indication rounds (pre-op) and discussion;
• fortnightly peer review learning (audit discussion);
• monthly tumour board;
• clinic attendance at the following clinics:
• General Paediatric and Adolescent Orthopaedics and Trauma Clinic
• Paediatric and Adolescent Spine and Scoliosis Clinic
• Paediatric and Adolescent Sports Injury Clinic
• Paediatric and Adolescent Foot and Ankle Clinic
• Paediatric Trauma and Congenital Hand Clinic
• Musculoskeletal Tumour Clinic
• Cerebral Palsy (CP) Clinic
• Birth related Brachial Plexus Palsy (BPP) Clinic
• Clubfoot (CTEV) Clinic
• Professorial Clinic for Complex Cases
• Lower Limb Length Discrepancy (LLD) and Deformity Clinics

To ensure holistic learning, the didactic teaching, combined structured case discussion and journal readings are coordinated to cover the same topic/s in a period.

Training Methods

1. Didactic lectures – core and departmental.
2. Structured case discussions with preplanned topics for discussion.
3. Combined teaching X-ray conferences with radiologists of preplanned cases for discussion.
4. Journal reading and critique
5. Mortality and morbidity case discussions
   
6. Teaching by specialists during specialty clinics (as noted above)
7. Clinical teaching at morning bedside rounds , outpatient clinics, operating theatres
8. Simulation training using plastics models to demonstrate Barlow/Ortolani, Clubfeet models to demonstrate Ponseti method
   

Past and Present Fellows

Some of our past fellows are:

Team of Experts

The Paediatric Orthopaedic Fellowship Programme is managed by the following experts:

II Assessment and Evaluation

Aims of Assessment

(A) Patient Care

Fellows must be proficient in:

1. interpreting and synthesising patient history, clinical examination, and diagnostic tests into differential diagnoses;
2. interpreting various laboratory, radiologic, and other diagnostic tests;
3. planning the appropriate treatment and surgery if required, based upon the diagnosis and clinical findings;
4. assisting in surgical procedures
   for conditions such as scoliosis surgery, limb length problems, tumours, neuromuscular disease, cerebral palsy, myelomeningocele, developmental deformities, DDH, Legg-Perthes Disease and congenital anomalies, commensurating with his/her level of medical knowledge.

Fellows should be able to handle common paediatric fractures. They are expected to be competent in the manipulation and reduction of fracture and also surgical management of common fractures such as supracondylar humerus fractures and lateral condylar humerus fractures.

(B) Medical Knowledge

Fellows must be equipped with the following knowledge:

1. the management of common paediatric fractures, including the indications for closed and open reduction. and the role of remodeling in paediatric fractures;
2. the natural history and assessment of angular and torsional deformities as well as understand the indications for orthotic and operative treatment for these deformities;
3. have a clear understanding of the evaluation and management of childhood and adolescent hip disorders (DDH, LCP, SCFE);
4. understand the evaluation and treatment of a child with a limp;
5. the assessment and management of back pain in the child and adolescent, and how it differs from an adult presentation;
6. the assessment of common foot problems in the pediatric patient. These include clubfoot deformities, flexible flat feet, cavovarus foot deformities, congenital vertical talus, lesser toes deformities, metatarsus adductus, and juvenile hallux valgus. The non-operative management and operative indications for each of these problems should be understood;
7. understand the evaluation and treatment of common paediatric sports overuse/injuries;
8. know the assessment, prioritisation, and management of paediatric polytrauma. Understand the indications for open reduction and internal fixation in children with multiple fractures associated closed head injury, and articular fractures;
9. understand the comprehensive evaluation and multidisciplinary management of neuromuscular disorders such as cerebral palsy, muscular dystrophy, and myelomeningocele. The indications for orthotic treatment and operative procedures specific for each individual disorder must be appreciated;
10. have a clear understanding of rehabilitation for common pediatric and adolescent hip disorders, traumatic brain injuries, and neuromuscular disorders such as cerebral palsy and myelomeningocele;
11. understand clinical gait analysis and common abnormal gait patterns;
12. the evaluation and management of pediatric spinal deformities, including the indications for orthotic and operative intervention. These deformities include idiopathic scoliosis, congenital and neuromuscular scoliosis, and Scheuermann’s kyphosis;
13. understand the clinical and radiographic presentation of common paediatric tumors, benign and malignant; their diagnostic work-up, staging, and operative indications;
14. know the assessment and etiologies of limb length discrepancies (LLD) in children, use of the Moseley straight-line graph to determine LLD at skeletal maturity, and the indications and options for operative intervention. 
    

(C) Practice-Based Learning and Improvement

Fellows must demonstrate commitment towards continuous learning and improvement in their patient care, benefiting from previous experiences and ongoing review of the literature, and contributing to the education of those around them, including:

1. contributing to the education of medical students and other healthcare professionals;
2. evaluating medical research/scientific evidence and applying findings to patient care, frequently utilising textbooks, reviewing articles and “classic” articles, and actively seeking out more recent and “cutting edge” manuscripts that are applicable to patient care;
3. monitoring their own practice of medicine to identify opportunities for improvement;
4. participating in the morbidity and mortality audit process;
5. effectively utilising information technology to manage and access medical information (these “e-Journals” are now readily available on the SingHealth’s website);
6. demonstrating increasing levels of independence with decreasing need for faculty supervision, commensurate with the medical knowledge and patient care competencies outlined above.
   

(D) Interpersonal and Communication Skills

Fellows must be respectful of patients and members of the healthcare team at all times, including:

1. demonstrating the ability to discuss difficult matters with patients and families in a compassionate manner. The level of discussion should commensurate with the medical knowledge and experience of the Fellow;
2. demonstrating the ability to allow patients and families to fully express their concerns and/or symptoms;
3. demonstrating the ability to explain operative procedures, risks and post-operative care to the patient/family, commensurate with their medical knowledge and experience;
4. demonstrating the ability to develop a professional relationship with the patient/family;
5. maintaining professional communications and relationships with ancillary staff and medical colleagues;
6. demonstrating effective communication in the informed consent process.
   

(E) Professionalism

Fellows must act professionally towards patients and members of the healthcare team at all times, including:

1. demonstrating sensitivity and responsiveness to differences in culture, gender, age and impairments;
2. demonstrating sensitivity to the needs of patients/families;
3. respecting the need for confidentiality of patient information;
4. always demonstrating honesty in written and oral communications.
5. demonstrating awareness of limitations and seek advice when appropriate;
6. accepting advice without personal offense and use it constructively;
7. assessing their own capabilities with objectivity and accuracy;
8. being on-time for all clinical responsibilities;
9. demonstrating respectful collaboration with their peers and allied health staff. 
   

(F) Systems-Based Practice

Fellows must recognise his/her role in a complex healthcare system; identify resources available to contribute to patient care, and demonstrate familiarity with internal and external regulations and policies that impact care delivery, including:

1. completing medical records accurately and in a timely manner;
2. effectively utilising healthcare system resources to provide optimal patient care;
3. being aware of the need to provide cost efficient patient care, and have a basic understanding of the factors that impact this, understanding the costs associated with their treatment recommendations, and be able to justify treatment not only on medical decision making but cost considerations as well;
4. assisting patients in dealing with healthcare complexities and serve as advocates for patients within the healthcare system;
5. being attentive to the manner in which the healthcare system may impact patient safety and take steps to prevent errors, including awareness of International, National and Hospital Patient Safety Goals and Improvement Projects;
6. being attentive to medication errors, surgical site infection and patient harm resulting from falls;
7. adhering to the standards of surgical site identification, awareness of wrong site surgery and adherence to surgical time out.
   

Assessment Approaches

Tentative schedule:

• Journal reading: 1 per 6 months
• Didactic teaching: 2 per 6 months
• Mini-CEX: 1 per 6 months
• Multi-rater 360 evaluation: 1 per 6 months
  

Evaluation Process

General overall grading system

The general overall grading system evaluates the Fellow’s performance upon completion of the fellowship programme. All Fellows will be given a general overall grading status at the end of the fellowship programme based on the grading criteria requirements incorporating the six competencies based knowledge, skills and performance that Fellows must demonstrate throughout the programme.

*Fellows who attained a USP grade are given options to extend their fellowship programmes or reapply. This will depend on the faculty's evaluation on the Fellow's clinical skills and professional attitude.

The attachment programme will be terminated early on the ground of the Fellow’s poor performance, misdemeanor, misconduct, negligence or breach of any terms stipulated or referred to in the Fellowship Letter of Offer and Institution Terms and Conditions.

The Fellow may also request to terminate the attachment programme for reasons such as serious illness or other personal obligations.

The institution will review all requests for early termination with the Fellow and the supervisor/ Head of Department.

III Target Audience and Eligibility Requirements

Target Audience

Preference will be given to a general orthopaedic surgeon who intends to specialise in paediatric orthopaedics. Candidates from wholly for-profit private institutions with no formal affiliation with a medical school will not be considered.

Pre-requisite/Eligibility Requirement(s)

Candidates must:

• be from an institution that is government supported and/or an AMC with an affiliation to a medical school. Verification of this will be required.
• be financially self-sufficient during the whole period of the fellowship as there will be no stipend or funding available.

IV Other Information

Course Fees

Course fee will be determined upon application.

Funding

We do not currently provide any form of funding for Fellows. Hence, candidates should be self-funded or have self-arranged funding from external sources or institutions.

Certification

Certificate of fellowship will be awarded upon completion of the programme.
This includes at the minimum:

• satisfactory log of surgical cases and procedures as assessed by supervisors and Head of Department
• satisfactory attendance based on planned schedule and involvement in department activities as assessed by supervisors and Head of Department;
• involvement in at least one research paper.