1
|
Silvestre J, Kang JD, Ravinsky RA, Lawrence JP, Reitman CA. Establishing case volume benchmarks for ACGME-accredited orthopedic surgery of the spine fellowship training. Spine J 2024:S1529-9430(24)00154-2. [PMID: 38554735 DOI: 10.1016/j.spinee.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/12/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND CONTEXT There has been increasing scrutiny on the standardization of surgical training in the US. PURPOSE This study provides case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic spine surgery fellowship training. STUDY DESIGN/SETTING This was a retrospective cross-sectional study of fellows at ACGME-accredited orthopedic spine surgery fellowships (2017-2022). PATIENT SAMPLE N/A. OUTCOME MEASURES Reported case volume during fellowship training. METHODS Case volume percentiles were calculated across ACGME-defined case categories and temporal changes assessed via linear regression. Variability between the highest and lowest deciles by case volume was calculated as fold-differences (90th percentile/10th percentile). Sensitivity analyses were performed to identify potential targets for case minimum requirements. RESULTS A total of 163 spine surgery fellows were included in this study. Total mean reported spine surgery case volume increased from 313.2±122 in 2017 to 382.0±164 in 2022 (p=.19). Most cases were classified as adult (range, 97.2%-98.0%) over pediatric cases (range, 2.0%-2.8%). An average of 322.0 cases were reported and most were classified as laminectomy (32%), posterior arthrodesis (29%), and anterior arthrodesis (20%). Overall variability in total case volume was 2.4 and the greatest variability existed for posterior instrumentation (38.1), application of cage (34.6), anterior instrumentation (20.8), and fractures and dislocations (17.3). If case minimum requirements for total reported cases was assumed at 200 cases, then all spine fellows included in this study would achieve this requirement. However, if case minimum requirements were assumed at 250 total cases, then approximately thirty percent of fellows (n=49) would not achieve this requirement for graduation. CONCLUSIONS Increasingly, national societies and accrediting bodies for surgical education recognize the need for standardized training. This study provides benchmarks to inform potential case minimum requirements and help reduce variability during spine fellowship training. Future studies are needed to establish case minimum requirements for spine surgery fellowship training across comprehensive and granular case categories that cover the full gamut of orthopedic spine surgery.
Collapse
Affiliation(s)
- Jason Silvestre
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA.
| | - James D Kang
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Robert A Ravinsky
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
| | - James P Lawrence
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
| | - Charles A Reitman
- Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA
| |
Collapse
|
2
|
Sarikonda A, Leibold A, Sivaganesan A. When Does Intervention End and Surgery Begin? The Role of Interventional Pain Management in the Treatment of Spine Pathology. Curr Pain Headache Rep 2023; 27:707-717. [PMID: 37713091 DOI: 10.1007/s11916-023-01165-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/16/2023]
Abstract
PURPOSE OF REVIEW Recent advances in the field of interventional pain management (IPM) involve minimally invasive procedures such as percutaneous lumbar decompression, interspinous spacer placement, interspinous-interlaminar fusion and sacroiliac joint fusion. These developments have received pushback from surgical professional societies, who state spinal instrumentation and arthrodesis should only be performed by spine surgeons. The purpose of this review is to evaluate the validity of this claim. A literature search was conducted on Google Scholar and PubMed databases. Articles were included which examined IPM in the following contexts: credentialing and procedural privileging guidelines, fellowship training and education, and procedural outcomes compared to those of surgical specialties. Our primary research question is: "Should interventionalists be performing decompression and fusion procedures?". FINDINGS Advanced percutaneous spine procedures are not universally incorporated into pain fellowship curriculums. Trainees attempt to compensate for these deficiencies through industry-led training, which has been criticized for lacking central regulation. There is also a paucity of studies comparing procedural outcomes between surgeons and interventionalists for complex spine procedures, including decompression and fusion. Pain fellowship curriculums have not kept pace with some of procedural advancements within the field. Interventionalists are also not trained to manage potential complications of spinal instrumentation and arthrodesis, which has been recognized as an essential requirement for procedural privileging. Decompression and fusion may therefore be outside the scope of an interventionalist's practice.
Collapse
Affiliation(s)
- Advith Sarikonda
- Department of Neurological Surgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 901 Walnut Street, Philadelphia, PA, 19107, USA
| | - Adam Leibold
- Department of Neurological Surgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 901 Walnut Street, Philadelphia, PA, 19107, USA
| | - Ahilan Sivaganesan
- Department of Neurological Surgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 901 Walnut Street, Philadelphia, PA, 19107, USA.
| |
Collapse
|
3
|
Kuruba V, Cherukuri AMK, Arul S, Alzarooni A, Biju S, Hassan T, Gupta R, Alasaadi S, Sikto JT, Muppuri AC, Siddiqui HF. Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders. Cureus 2023; 15:e45962. [PMID: 37900519 PMCID: PMC10600402 DOI: 10.7759/cureus.45962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.
Collapse
Affiliation(s)
- Venkataramana Kuruba
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Vijayawada, IND
| | | | - Subiksha Arul
- Department of Medicine, JONELTA Foundation School of Medicine, University of Perpetual Help System DALTA, Manila, PHL
| | | | - Sheryl Biju
- Department of Medicine, Christian Medical College, Vellore, IND
| | - Taimur Hassan
- Department of Medicine, Texas A&M College of Medicine, College Station, USA
| | - Riya Gupta
- Department of Medicine, Shri Atal Bihari Vajpayee Medical College and Research Institute, Bangalore, IND
| | - Saya Alasaadi
- Department of Medicine, University College of Dublin, Dublin, IRL
| | - Jarin Tasnim Sikto
- Department of Medicine, Jahurul Islam Medical College and Hospital, Bhagalpur, BGD
| | - Arnav C Muppuri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Humza F Siddiqui
- Department of Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
| |
Collapse
|
4
|
McDonald CL, Berreta RAS, Alsoof D, Homer A, Molino J, Ames CP, Shaffrey CI, Hamilton DK, Diebo BG, Kuris EO, Hart RA, Daniels AH. Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty. Spine J 2023; 23:1365-1374. [PMID: 37236366 DOI: 10.1016/j.spinee.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/16/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND CONTEXT Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality. PURPOSE The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample. STUDY DESIGN/SETTING Retrospective cohort study using an administrative claims database. PATIENT SAMPLE A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons. OUTCOME MEASURES The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total). METHODS The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521. RESULTS A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery. CONCLUSIONS This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.
Collapse
Affiliation(s)
- Christopher L McDonald
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Rodrigo A Saad Berreta
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Daniel Alsoof
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Alex Homer
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Janine Molino
- Department of Orthopedics, Biostatistics Division, Brown University Warren Alpert Medical School, Grads Dorm Building 3rd Floor, Rhode Island Hospital 593 Eddy St, 02903, Providence, RI, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, Eighth Floor, 400 Parnassus Ave, CA 94143, San Francisco, California
| | - Christopher I Shaffrey
- Department of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Lothrop Street, A402 UPMC Presbyterian, PA 15213, Pittsburgh, Pennsylvania
| | - Bassel G Diebo
- Swedish Neuroscience Institute, 550 17th Avenue, James Tower, Suite 500, 98122, Seattle, WA
| | - Eren O Kuris
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, 550 17th Avenue, James Tower, Suite 500, 98122, Seattle, WA
| | - Alan H Daniels
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA.
| |
Collapse
|
5
|
Daniels AH, Alsoof D, McDonald CL, Zhang AS, Diebo BG, Eberson CP, Kuris EO, Lavelle W, Ames CP, Shaffrey CI, Hart RA. Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors. JB JS Open Access 2023; 8:e23.00050. [PMID: 37533873 PMCID: PMC10393084 DOI: 10.2106/jbjs.oa.23.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted. Methods This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years. Results In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05). Conclusion Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway. Level of Evidence IV.
Collapse
Affiliation(s)
- Alan H. Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel Alsoof
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christopher L. McDonald
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew S. Zhang
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Orthopedic Surgery, LSU Shreveport, Shreveport, Louisiana
| | - Bassel G. Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Craig P. Eberson
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Eren O. Kuris
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - William Lavelle
- Department of Orthopedic Surgery, Upstate University Hospital, Syracuse, New York
| | - Christopher P. Ames
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California
| | | | - Robert A. Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| |
Collapse
|
6
|
Silvestre J, Wu HH, Thompson TL, Kang JD. Utility of Spine Surgery Fellowship Training for Orthopaedic Surgeons in the United States. J Am Acad Orthop Surg 2023; 31:335-340. [PMID: 36729747 DOI: 10.5435/jaaos-d-22-00788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/21/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Orthopaedic spine surgeons gain surgical experience through cases conducted during residency and fellowship training. This study elucidates the incremental benefit in spine surgery volume from orthopaedic spine surgery fellowship training. METHODS This was a retrospective national cohort study of orthopaedic surgery residents and orthopaedic spine surgery fellows graduating from US Accreditation Council for Graduate Medical Education-accredited training programs during the 2017 to 2020 academic years. Comparisons in spine surgery case volume were made with parametric tests. RESULTS One hundred fourteen spine surgery fellows and 3,000 orthopaedic surgery residents were included. There was a 3.5-fold increase in total spine surgery cases conducted during fellowship versus residency (314 ± 129 vs. 89 ± 61, P < 0.001). Spine surgery fellows one standard deviation more than the mean reported 443 total spine cases. The largest differences between fellows and residents were Decompression (104 ± 48 vs. 28 ± 23, P < 0.001), Posterior Arthrodesis (94 ± 46 vs. 21 ± 18, P < 0.001), Anterior Arthrodesis (64 ± 31 vs. 13 ± 13, P < 0.001), and Instrumentation (43 ± 25 vs. 22 ± 12, P < 0.001). DISCUSSION Spine surgery fellowship training affords orthopaedic surgeons the opportunity to increase spine surgery case volume by over threefold. The greatest increases in case volume were reported for Decompression, Posterior Arthrodesis, Anterior Arthrodesis, and Instrumentation.
Collapse
Affiliation(s)
- Jason Silvestre
- From Howard University College of Medicine, Washington, DC (Silvestre and Thompson), University of California San Francisco School of Medicine, San Francisco, CA (Wu), and Brigham and Women's Hospital, Boston, MA (Kang)
| | | | | | | |
Collapse
|
7
|
Should We Hire Our Current Fellow? Hiring Trends and Preferences in Spine Surgery. J Am Acad Orthop Surg 2023; 31:e207-e215. [PMID: 36729972 DOI: 10.5435/jaaos-d-22-00445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/22/2022] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To provide insight into hiring trends/preferences in Academic Orthopaedic Spine Surgery after fellowship training. METHODS Fellowship directors (FDs) listed by the North American Spine Society were surveyed regarding new faculty hiring preferences. Surveys were analyzed/stratified by response using the Kruskal-Wallis with Dunn multiple comparisons test, the Fisher exact test, and the Mann-Whitney U test for univariate comparisons. RESULTS Thirty-two of 52 (61.5%) FDs responded. 32.3% of graduated fellows pursued academic medicine, which was preferred by FDs (3.59 ± 0.67; 1 to 5 scale). From 2015 to 2020, of the 2.25 ± 1.46 faculty members hired per program, 45.8% were former residents/fellows. Top listed hiring qualities were "strong recommendation from a trusted colleague" (84.4%), "prior personal experience, as a resident/fellow" (78.1%), and "amicable personality" (53.1%). Twelve (38%) answered "no", six (19%) "yes", and 14 (44%) "other", regarding if hiring former residents/fellows benefits the field of spine surgery. "Other" answers endorsing in-house hiring most commonly mentioned consistency/stability (28.6%) while those opposed most commonly mentioned lack of diversity of training/novel techniques (42.9%). When considering programmatic size, while the stated perception of FDs regarding in-house hiring at larger (>2 fellows) versus smaller (1 to 2 fellows) programs was equivalent, the mean percentage of in-house hires at larger programs (67.8% ± 35.8%) was significantly greater than that of smaller programs (33.3% ± 44.8%, P = 0.04). CONCLUSIONS In-house hiring in spine surgery appears to occur more commonly than perceived by program leadership, particularly at larger fellowship programs. Further study of hiring preferences and their impact on the field of spine surgery is warranted. STUDY DESIGN Prospective Survey Study.
Collapse
|
8
|
Vallejo FA, Schachner B, VanderVeer-Harris N, Torres AA, Weng J, Chang H, Bollo R, Ragheb J. A snapshot of contemporary leadership at pediatric neurosurgery fellowships. J Neurosurg Pediatr 2022; 30:532-537. [PMID: 36087318 DOI: 10.3171/2022.7.peds22133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Many pathways to positions of leadership exist within pediatric neurological surgery. The authors sought to investigate common trends in leadership among pediatric neurosurgery fellowship directors (FDs) and describe how formalized pediatric neurosurgical training arrived at its current state. METHODS Fellowship programs were identified using the Accreditation Council for Pediatric Neurosurgery Fellowships website. Demographic, training, membership, and research information was collected via email, telephone, curricula vitae, and online searches. RESULTS The authors' survey was sent to all 35 identified FDs, and 21 responses were received. Response data were supplemented with curricula vitae and online data prior to analysis. FDs were predominantly male, self-identified predominantly as Caucasian, and had a mean age of 53 years. The mean duration from residency graduation until FD appointment was 13.4 years. The top training programs to produce future FDs were New York University and Washington University in St. Louis (residency) and Washington University in St. Louis (fellowship). CONCLUSIONS This study characterizes the current state of pediatric neurosurgery fellowship program leadership. The data serve as an important point of reference to compare with future leadership as well as contrast with neurosurgery and other surgical disciplines in general.
Collapse
Affiliation(s)
| | | | | | - Adrian A Torres
- 3Florida State University College of Medicine, Tallahassee, Florida
| | - John Weng
- 3Florida State University College of Medicine, Tallahassee, Florida
| | - Henry Chang
- 1University of Miami Miller School of Medicine, Miami
| | - Robert Bollo
- 4Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - John Ragheb
- 5Department of Neurosurgery, University of Miami Miller School of Medicine, Miami; and
- 6Division of Neurosurgery, Brain Institute, Nicklaus Children's Hospital, Miami, Florida
| |
Collapse
|
9
|
Hart RA, Daniels AH, Shah K, Amendola AA, Harner CD, Marsh LL, Kenter K, Hu S. Is It Time to Create Training Pathways Allowing Earlier Subspecialization within the "House of Orthopaedics"?: AOA Critical Issues. J Bone Joint Surg Am 2022; 104:e52. [PMID: 35133994 DOI: 10.2106/jbjs.20.02166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The ability to train an orthopaedic resident in all aspects of orthopaedics in 5 years has become increasingly difficult due to the growth in knowledge and techniques, work-hour restrictions, and reduced resident autonomy. It has become nearly universal for our residents to complete at least 1 subspecialty fellowship prior to entering practice. In some subspecialties, the skills necessary to practice competently have become difficult to master. Simply adding to the current length of training may not address these issues effectively and would add to the economic cost of residency training. Novel training pathways that allow residents to focus earlier and in greater depth on their intended subspecialty while maintaining general orthopaedic competencies can be created without lengthening training. It is time to initiate discussions about these possibilities.
Collapse
Affiliation(s)
| | - Alan H Daniels
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | | | | | | | - Keith Kenter
- Western Michigan University, Kalamazoo, Michigan
| | - Serena Hu
- Stanford University, Palo Alto, California
| |
Collapse
|
10
|
Lad M, Gupta R, Para A, Gupta A, White MD, Agarwal N, Moore JM, Heary RF. An ACGME-based comparison of neurosurgical and orthopedic resident training in adult spine surgery via a case volume and hours-based analysis. J Neurosurg Spine 2021; 35:553-563. [PMID: 34359032 DOI: 10.3171/2020.10.spine201066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In a 2014 analysis of orthopedic and neurological surgical case logs published by the Accreditation Council for Graduate Medical Education (ACGME), it was reported that graduating neurosurgery residents performed more than twice the number of spinal procedures in their training compared with graduating orthopedic residents. There has, however, been no follow-up assessment of this trend. Moreover, whether this gap in case volume equates to a similar gap in procedural hours has remained unstudied. Given the association between surgical volume and outcomes, evaluating the status of this disparity has value. Here, the authors assess trends in case volume and procedural hours in adult spine surgery for graduating orthopedic and neurological surgery residents from 2014 to 2019. METHODS A retrospective analysis of ACGME case logs from 2014 to 2019 for graduating orthopedic and neurological surgery residents was conducted for adult spine surgeries. Case volume was converted to operative hours by using periprocedural times from the 2019 Medicare/Medicaid Physician Fee Schedule. Graduating residents' spinal cases and hours, averaged over the study period, were compared between the two specialties by using 2-tailed Welch's unequal variances t-tests (α = 0.05). Longitudinal trends in each metric were assessed by linear regression followed by cross-specialty comparisons via tests for equality of slopes. RESULTS From 2014 to 2019, graduating neurosurgical residents logged 6.8 times as many spinal cases as their orthopedic counterparts, accruing 431.6 (95% CI 406.49-456.61) and 63.8 (95% CI 57.08-70.56) cases (p < 0.001), respectively. Accordingly, graduating neurosurgical residents logged 6.1 times as many spinal procedural hours as orthopedic surgery residents, accruing 1020.7 (95% CI 964.70-1076.64) and 166.6 (95% CI 147.76-185.35) hours (p < 0.001), respectively. Over these 5 years, both fields saw a linear increase in graduating residents' adult spinal case volumes and procedural hours, and these growth rates were higher for neurosurgery (+16.2 cases/year vs +4.4 cases/year, p < 0.001; +36.4 hours/year vs +12.4 hours/year, p < 0.001). CONCLUSIONS Graduating neurosurgical residents accumulated substantially greater adult spinal case volumes and procedural hours than their orthopedic counterparts from 2014 to 2019. This disparity has been widened by a higher rate of growth in adult spinal cases among neurosurgery residents. Accordingly, targeted efforts to increase spinal exposure for orthopedic surgery residents-such as using cross-specialty collaboration-should be explored.
Collapse
Affiliation(s)
- Meeki Lad
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Raghav Gupta
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashok Para
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Arjun Gupta
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Michael D White
- 3Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nitin Agarwal
- 3Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Justin M Moore
- 4Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Robert F Heary
- 5Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
| |
Collapse
|
11
|
Bernatz JT, Johnson KP, Stokman JJ, Cannada LK, Williams SK, Whiting PS. Factors Considered in Ranking Spine Surgery Fellowship Applicants: A Survey of Program Directors. Spine (Phila Pa 1976) 2021; 46:882-885. [PMID: 33428366 DOI: 10.1097/brs.0000000000003938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVE To determine which factors spine surgery fellowship program directors (PDs) consider most important when ranking applicants. SUMMARY OF BACKGROUND DATA Spine surgery is a popular orthopedic subspecialty. As such, the spine fellowship match process is highly competitive. Surveys of fellowship PDs in orthopedic sports medicine and hand surgery have demonstrated differing opinions regarding factors considered most important when ranking fellowship applicants. The factors considered important to spine surgery fellowship PDs have not been evaluated. METHODS A web-based questionnaire was sent to the PDs of all spine surgery fellowships participating in the San Francisco (SF) Match Program. The questions were designed to identify criteria considered most important in ranking spine surgery fellowship applicants. A list of 12 criteria was presented and PDs were asked to rank these in order of importance. A weighted score for each criterion was calculated using the following scale: 5 points for each criterion ranked 1st, 4 points for 2nd, 3 points for 3rd, 2 points for 4th, and 1 point for 5th. RESULTS Of the 73 PDs queried, 52 responded (71% response rate). The interview was the most important factor when ranking fellowship applicants. The other criteria deemed most important in order of weighted scoring were letters of recommendation and personal connections to the applicant and/or familiarity with the applicant's letter writer(s). CONCLUSION Spine surgery fellowship PDs consider the interview, letters of recommendation, and personal connections with the applicant/letter writers to be the most important factors when ranking candidates. These results may be valuable to orthopedic residents and mentors of those pursuing fellowship training in spine surgery.Level of Evidence: 4.
Collapse
Affiliation(s)
- James T Bernatz
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kristina P Johnson
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - James J Stokman
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Lisa K Cannada
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine - Jacksonville, Jacksonville, FL
| | - Seth K Williams
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
12
|
Shofler D, To A, Cramer K, Batra S. Fellowships in Podiatric Medicine. J Foot Ankle Surg 2021; 59:1201-1208. [PMID: 32863116 DOI: 10.1053/j.jfas.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/13/2019] [Accepted: 06/01/2020] [Indexed: 02/03/2023]
Abstract
Graduating podiatric medicine and surgery residents are increasingly likely to pursue fellowship training. Nonetheless, there has been a lack of formal characterization of fellowship training in the field. The present study aimed to characterize fellowship training through an online survey. Two separate surveys were created, 1 for fellowship directors and 1 for fellows. Fellowship directors and fellows were asked questions pertaining to daily responsibilities, quality of training, work-life balance, the application process, fellow selection, and program selection. A total of 33 fellowship directors and 49 fellows responded to the survey, which was delivered over a 2-year period. Overall, fellows were generally satisfied with their respective programs, though greater satisfaction was associated with increased time allowed for research, as well as greater perceived quality of research training, clinical training, surgical training, and practice management training. When selecting a program, the 3 highest-rated factors were focus of the program, reputation of the fellowship director, and career options, and the 3 most important foot and ankle topics were hindfoot/ankle arthrodesis surgery, arthroscopy, and trauma. Open-ended responses from both fellowship directors and fellows reflected a range of opinions and recommendations, which may be helpful for future fellows or for fellowship program faculty. Notably, both fellowship directors and fellows commonly reported that the application process was in need of improvement, with increased standardization of the application process suggested. The results of the present study reflect baseline data on the topic, and may help facilitate improvement of the fellowship experience.
Collapse
Affiliation(s)
- David Shofler
- Assistant Professor, Department of Podiatric Medicine, Surgery, and Biomechanics, Western University College of Podiatric Medicine, Pomona, CA.
| | - Arthur To
- Podiatric Medical Student, Department of Podiatric Medicine, Surgery, and Biomechanics, Western University College of Podiatric Medicine, Pomona, CA
| | - Kira Cramer
- Podiatric Medical Student, Department of Podiatric Medicine, Surgery, and Biomechanics, Western University College of Podiatric Medicine, Pomona, CA
| | - Samta Batra
- Podiatric Medical Student, Department of Podiatric Medicine, Surgery, and Biomechanics, Western University College of Podiatric Medicine, Pomona, CA
| |
Collapse
|
13
|
Schiller NC, Sama AJ, Spielman AF, Donnally III CJ, Schachner BI, Damodar DM, Dodson CC, Ciccotti MG. Trends in leadership at orthopaedic surgery sports medicine fellowships. World J Orthop 2021; 12:412-422. [PMID: 34189079 PMCID: PMC8223724 DOI: 10.5312/wjo.v12.i6.412] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/05/2021] [Accepted: 06/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fellowship directors (FDs) in sports medicine influence the future of trainees in the field of orthopaedics. Understanding the characteristics these leaders share must be brought into focus. For all current sports medicine FDs, our group analyzed their demographic background, institutional training, and academic experience.
AIM To serve as a framework for those aspiring to achieve this position in orthopaedics and also identify opportunities to improve the position.
METHODS Fellowship programs were identified using both the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America Sports Medicine Fellowship Directories. The demographic and educational background data for each FD was gathered via author review of current curriculum vitae (CVs). Any information that was unavailable on CV review was gathered from institutional biographies, Scopus Web of Science, and emailed questionnaires. To ensure the collection of as many data points as possible, fellowship program coordinators, orthopaedic department offices and FDs were directly contacted via phone if there was no response via email. Demographic information of interest included: Age, gender, ethnicity, residency/fellowship training, residency/fellowship graduation year, year hired by current institution, time since training completion until FD appointment, length in FD role, status as a team physician and H-index.
RESULTS Information was gathered for 82 FDs. Of these, 97.5% (n = 80) of the leadership were male; 84.15% (n = 69) were Caucasian, 7.32% (n = 6) were Asian-American, 2.44% (n = 2) were Hispanic and 2.44% (n = 2) were African American, and 3.66% (n = 3) were of another race or ethnicity. The mean age of current FDs was 56 years old (± 9.00 years), and the mean Scopus H-index was 23.49 (± 16.57). The mean calendar years for completion of residency and fellowship training were 1996 (± 15 years) and 1997 (± 9.51 years), respectively. The time since fellowship training completion until FD appointment was 9.77 years. 17.07% (n = 14) of FDs currently work at the same institution where they completed residency training; 21.95% (n = 18) of FDs work at the same institution where they completed fellowship training; and 6.10% (n = 5) work at the same institution where they completed both residency and fellowship training. Additionally, 69.5% (n = 57) are also team physicians at the professional and/or collegiate level. Of those that were found to currently serve as team physicians, 56.14% (n = 32) of them worked with professional sports teams, 29.82% (n = 17) with collegiate sports teams, and 14.04% (n = 8) with both professional and collegiate sports teams. Seven residency programs produced the greatest number of future FDs, included programs produced at least three future FDs. Seven fellowship programs produced the greatest number of future FDs, included programs produced at least four future FDs. Eight FDs (9.75%) completed two fellowships and three FDs (3.66%) finished three fellowships. Three FDs (3.66%) did not graduate from any fellowship training program. The Scopus H-indices for FDs are displayed as ranges that include 1 to 15 (31.71%, n = 26), 15 to 30 (34.15%, n = 28), 30 to 45 (20.73%, n = 17), 45 to 60 (6.10%, n = 5) and 60 to 80 (3.66%, n = 3). Specifically, the most impactful FD in research currently has a Scopus H-index value of 79. By comparison, the tenth most impactful FD in research had a Scopus H-index value of 43 (accessed December 1, 2019).
CONCLUSION This study provides an overview of current sports medicine FDs within the United States and functions as a guide to direct initiatives to achieve diversity equality.
Collapse
Affiliation(s)
- Nicholas C Schiller
- Miller School of Medicine, University of Miami, Miami, FL 33136, United States
| | - Andrew J Sama
- Miller School of Medicine, University of Miami, Miami, FL 33136, United States
| | - Amanda F Spielman
- Miller School of Medicine, University of Miami, Miami, FL 33136, United States
| | - Chester J Donnally III
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107, United States
| | | | - Dhanur M Damodar
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL 33316, United States
| | - Christopher C Dodson
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Michael G Ciccotti
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107, United States
| |
Collapse
|
14
|
Leadership trends among orthopaedic trauma surgery fellowship directors: a cross-sectional demographic review. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000000977] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Schiller NC, Donnally CJ, Sama AJ, Schachner BI, Wells ZS, Austin MS. Trends in Leadership at Orthopedic Surgery Adult Reconstruction Fellowships. J Arthroplasty 2020; 35:2671-2675. [PMID: 32507452 DOI: 10.1016/j.arth.2020.04.091] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Fellowship directors (FDs) in adult reconstruction have a profound impact on current and future trainees within orthopedics. Our group sought to evaluate the shared characteristics among current adult reconstruction FDs to provide a framework for those aspiring to achieve this position and identify possible areas of improvement. METHODS Fellowship programs were identified using the American Association of Hip and Knee Surgeons Directory. Data for each FD were gathered via electronic mail, telephone, curriculum vitae, and online searches. Demographic information collected included age, gender, ethnicity, residency/fellowship training, residency/fellowship graduation year, year hired by current institution, time since training completion until FD appointment, length in FD role, and Scopus H-index. RESULTS Information was gathered for 94 FDs. Of these, 100% were males; 80.6% were Caucasian, 12.90% were Asian American, 5.38% were Hispanic, and 1.08% were African American. The average age (52.6 years old), H-index (16.54), year of residency (2000) and fellowship (2001) graduation, and time since training until FD appointment (9.55 years) were analyzed. The top training programs to produce future FDs were Mayo Clinic (residency) and Harvard University (fellowship). CONCLUSION Adult reconstruction FDs are frequently distinguished by their level of research productivity and experience, but certainly more demographic diversity is needed within this cohort. Specific training programs may inherently have a vital role in the development of individuals for future leadership positions. These developments could be a result of unique features inherent to the training programs or because of a subset of applicants who pursue specific programs with aspirations of subsequent leadership opportunities.
Collapse
Affiliation(s)
- Nicholas C Schiller
- Department of Education, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Chester J Donnally
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew J Sama
- Department of Education, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Benjamin I Schachner
- Department of Education, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Zachary S Wells
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Matthew S Austin
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
16
|
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVE To illustrate demographic trends among spine fellowship leaders (FLs). SUMMARY OF BACKGROUND DATA No previous study in the orthopedic literature has analyzed the demographic characteristics or past surgical training of FL in an orthopedic sub-specialty. We attempt to illustrate demographic trends among spine fellowship leadership including fellowship directors (FDs) and co-fellowship directors (co-FDs). We also highlight the institutions that have trained these leaders at various levels. METHODS Our search for FDs was constructed from the 2018 to 2019 North American Spine Surgery (NASS) Fellowship Directory. Datapoints gathered included: age, sex, residency/fellowship training location, time since training completion until FD appointment, length in FD role, and personal research H-index. RESULTS We identified 103 FLs consisting of 67 FDs, 19 co-FDs, and another 16 individuals with a synonymous leadership title. 96.1% (99) of the leadership consisted of males while 3.9% (4) were female. The mean age was 52.9 years old and the mean h-index of the FLs was 23.8. FLs were trained in orthopedic surgery (n = 89), neurosurgery (n = 13), or combined orthopedic surgery and neurosurgery training (n = 1). The top fellowships programs producing future FLs were: Case Western Reserve University, Cleveland (n = 10), Washington University, St. Louis (n = 9), and Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia (n = 7). CONCLUSION Spine surgery fellowship directors are more likely to have graduated from certain residency and fellowship programs. This finding could be a result of the training provided by these centers or the institution's predilection to select applicants that are more likely to later seek academic leadership roles post-training. LEVEL OF EVIDENCE 4.
Collapse
|
17
|
Malik AT, Baek J, Alexander JH, Khan SN, Scharschmidt TJ. Orthopaedic vs. Neurosurgery - Does a surgeon's specialty have an influence on 90-day complications following surgical intervention of spinal metastases? Clin Neurol Neurosurg 2020; 192:105735. [PMID: 32078956 DOI: 10.1016/j.clineuro.2020.105735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/02/2020] [Accepted: 02/09/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Spinal metastases are routinely managed and/or operated on by both orthopaedic surgeons and neurological surgeons. However, controversy still exists as to whether the operating surgeon's specialty has an impact on post-operative complication rates. PATIENTS AND METHODS The 2007-2017 Humana Administrative Claims database was queried using Current Procedural Terminology codes to identify patients undergoing fusions, laminectomies or osteotomy/corpectomy for spinal metastases. Physician taxonomy codes were used to identify the operating surgeon's specialty (orthopaedic vs. neurosurgery). Multivariate logistic regression analyses were used to assess difference in 90-day complications, readmissions and mortality between the two specialties while controlling for age, gender, race, co-morbidity burden, procedural characteristics (fusion, laminectomy and/or osteotomy/corpectomy) and type of primary cancer. RESULTS A total of 887 patients undergoing surgical intervention for spinal metastases were included - out of which 204 (23.0 %) patients were operated on by orthopaedic surgeons and 683 (77.0 %) by neurosurgeons. Following adjustment for difference in patient demographics and baseline clinical characteristics, no statistically significant differences were noted between the two specialties with regards to wound complications (p = 0.992), pulmonary complications (p = 0.461), cardiac complications (p = 0.631), thrombotic complications (p = 0.177), sepsis (p = 0.463), pneumonia (p = 0.767), urinary tract infection (p = 0.916), acute renal failure (p = 0.934), hardware complications (p = 0.892), emergency department visits (p = 0.934), 90-day readmissions (p = 0.277) and 90-day mortality (p = 0.786). CONCLUSIONS Based off our findings, it appears that a surgeon's specialty has no influence on intermediate-term complications following surgical intervention for spinal metastases. The findings of the study should support the need for maintaining access of patients to both specialties for appropriate surgical consultation.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Division of Spine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States; Division of Musculoskeletal Oncology, Department of Orthopaedics, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States
| | - Jae Baek
- Division of Spine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States; Division of Musculoskeletal Oncology, Department of Orthopaedics, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States
| | - John H Alexander
- Division of Musculoskeletal Oncology, Department of Orthopaedics, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States
| | - Safdar N Khan
- Division of Spine, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States
| | - Thomas J Scharschmidt
- Division of Musculoskeletal Oncology, Department of Orthopaedics, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, United States.
| |
Collapse
|
18
|
Pham MH, Jakoi AM, Wali AR, Lenke LG. Trends in Spine Surgery Training During Neurological and Orthopaedic Surgery Residency: A 10-Year Analysis of ACGME Case Log Data. J Bone Joint Surg Am 2019; 101:e122. [PMID: 31764374 DOI: 10.2106/jbjs.19.00466] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Spine surgery training in the United States currently involves residency training in neurological or orthopaedic surgery. Because of different core residency surgical requirements, the volume of spine surgery procedures may vary between the 2 residencies. METHODS We reviewed the Accreditation Council for Graduate Medical Education resident case logs for both orthopaedic surgery and neurological surgery for exposure to spine surgery procedures for the graduating years of 2009 to 2018. RESULTS The average number of spine surgery procedures performed during that 10-year period was 433.8 for neurosurgery residents and 119.5 for orthopaedic surgery residents (p < 0.01). From 2009 to 2018, neurosurgery residents saw an increase of 26.5% in spine surgery procedures (from 389.6 to 492.9 procedures), whereas orthopaedic surgery residents saw a decrease of 41.3% (from 141.1 to 82.8 procedures). The 10-year average percentage of total spine procedures among all total surgical cases was 33.5% for neurosurgery residents compared with 6.2% for orthopaedic surgery residents (p < 0.01). This percentage decreased for both neurosurgery residents (35.8% in 2009 to 31.3% in 2018) and orthopaedic surgery residents (7.2% in 2009 to 4.9% in 2018). Neurosurgical residents performed 3.6 times more total spine procedures than orthopaedic surgery residents on average, a number that increased from 2.8-fold in 2009 to 6.0-fold in 2018. CONCLUSIONS The case volume of spine surgery procedures varies greatly, with higher rates for neurological surgery and lower rates for orthopaedic surgery residencies, with an increasing discrepancy over time. Although case volume alone cannot solely determine quality of training, it is one measure to assess opportunities to develop optimal spine education around a certain accepted volume of surgical patient care. Not accounted for here are additional postgraduate spine cases performed by orthopaedic surgery residents who pursue spine fellowship training (an additional 300 to 500 cases). The results described herein may help to explore the various needs of and differences between residents seeking to pursue careers in spine as well as the role of spine surgery fellowships currently and in the future.
Collapse
Affiliation(s)
- Martin H Pham
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California
| | - Andre M Jakoi
- Orthopedic Health of Kansas City, North Kansas City, Missouri
| | - Arvin R Wali
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, California
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, The Daniel and Jane Och Spine Hospital at New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| |
Collapse
|
19
|
The Role of Athletic Event Coverage in Orthopaedic Residency Training: A National Survey of Residency Program Directors. J Am Acad Orthop Surg 2019; 27:365-369. [PMID: 30320733 DOI: 10.5435/jaaos-d-18-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION No Accreditation Council for Graduate Medical Education guidelines exist regarding athletic event coverage by orthopaedic residents. This study assesses the availability and characteristics of event coverage opportunities in residency programs. METHODS An anonymous web-based survey assessing resident athletic event coverage opportunities was distributed to members (n = 158) of the American Orthopaedic Association's Council of Orthopaedic Residency Directors. RESULTS The survey response rate was 39% (n = 62). Most of the programs (76%) offer athletic event coverage opportunities for residents, most (54%) of which are optional. Of the programs with coverage opportunities, 34 (74%) have a teaching curriculum and 10 (22%) report that residents are always under the direct supervision of an attending orthopaedic surgeon. Thirty programs (64%) count the time spent at athletic events toward duty hours. DISCUSSION A comprehensive and uniform resident experience for athletic event coverage does not exist. This finding may represent an area of deficiency in orthopaedic training requiring enhanced national standards.
Collapse
|
20
|
Johans SJ, Hofler RC, Nockels RP. Management of Adolescent Idiopathic Scoliosis: Institutional Experience, Integration into Neurosurgical Practice, and Impact on Resident Training. World Neurosurg 2019; 126:e181-e189. [PMID: 30797921 DOI: 10.1016/j.wneu.2019.01.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Management of adolescent idiopathic scoliosis (AIS) in neurosurgery residency training may have a significant impact on resident experience, even though few trainees are likely to pursue careers in the field of AIS. The impact of this exposure on resident knowledge in adult spinal disease management is the subject of our retrospective analysis. METHODS An analysis was performed of all adolescent patients undergoing surgical correction of spinal deformity between 2006 and 2016. Patient characteristics, including age at operation, Cobb angles, length of stay, operative time, blood loss, and complications, were collected. Objective benchmarks were created for resident education in the management of AIS. A survey was sent to the last 7 years of graduates to assess the impact of exposure to AIS during neurosurgery training on their current practice. RESULTS Nine male and 37 female patients ages 11 to 22 years were identified. Neurosurgical residents assisted in all procedures without fellows or surgical assistants. Average operative time was 336 minutes (range, 215-575 minutes), and blood loss per procedure was 603 mL (range, 200-4000 mL). The average Cobb angle correction was 72.2% (range, 35.3%-90.9%). Zero of the past 7 graduates currently treat AIS surgically. All 7 graduates agreed that exposure to AIS during residency enhanced their knowledge of adult spinal disease management. CONCLUSIONS Treatment of AIS by surgeons with specialized training can be effective and safe. Resident exposure to these patients enhances their understanding of spinal biomechanics and deformity correction, which is applicable to treating AIS and adult spinal deformity.
Collapse
Affiliation(s)
- Stephen J Johans
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Ryan C Hofler
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Russ P Nockels
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA.
| |
Collapse
|
21
|
Esfahani DR, Shah H, Arnone GD, Scheer JK, Mehta AI. Lumbar Discectomy Outcomes by Specialty: A Propensity-Matched Analysis of 7464 Patients from the ACS-NSQIP Database. World Neurosurg 2018; 118:e865-e870. [PMID: 30031193 DOI: 10.1016/j.wneu.2018.07.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Darian R Esfahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Harsh Shah
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gregory D Arnone
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Justin K Scheer
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
| |
Collapse
|
22
|
Bronheim RS, Cheung ZB, Phan K, White SJW, Kim JS, Cho SK. Anterior Lumbar Fusion: Differences in Patient Selection and Surgical Outcomes Between Neurosurgeons and Orthopaedic Surgeons. World Neurosurg 2018; 120:e221-e226. [PMID: 30121412 DOI: 10.1016/j.wneu.2018.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Anterior lumbar fusion (ALF) is performed by both neurosurgeons and orthopaedic surgeons. The aim of this study was to determine differences between the 2 surgical subspecialties in terms of patient selection and postoperative outcomes after ALF. METHODS A retrospective cohort study of adult patients undergoing ALF in the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014 was performed. Univariate analyses were performed to identify differences in baseline patient demographics, comorbidities, operative characteristics, and 30-day postoperative outcomes between neurosurgery and orthopaedic surgery patients. Multivariate logistic regression analysis was used to determine whether surgical subspecialty was an independent risk factor for postoperative complications. RESULTS The study included 3182 patients, with 1629 (51.2%) neurosurgery patients and 1553 (48.8%) orthopaedic surgery patients. A greater proportion of neurosurgery patients were >65 years old, were being treated with preoperative steroids, had cardiac or pulmonary comorbidities, and had an American Society of Anesthesiologists classification III or higher. ALF procedures performed by neurosurgeons more frequently involved use of intervertebral devices and bone graft. On multivariate logistic regression analysis, ALF procedures performed by neurosurgeons were independently associated with a higher risk of reoperation (odds ratio = 1.61; 95% confidence interval, 1.02-2.56; P = 0.042) and urinary tract infection (odds ratio = 1.94; 95% confidence interval, 1.02-3.68; P = 0.043). CONCLUSIONS In addition to differences in baseline patient demographics and comorbidities and operative characteristics, ALF performed by neurosurgeons had a higher risk of 30-day reoperation and urinary tract infection compared with ALF performed by orthopaedic surgeons.
Collapse
Affiliation(s)
- Rachel S Bronheim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin Phan
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia; Department of Neurosurgery, Prince of Wales Hospital, Randwick, Sydney, Australia
| | - Samuel J W White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
23
|
Grabel ZJ, Hart RA, Clark AJ, Park SH, Shaffrey CI, Scheer JK, Smith JS, Kelly MP, DePasse JM, Gupta MC, Ames CP, Daniels AH. Adult Spinal Deformity Knowledge in Orthopedic Spine Surgeons: Impact of Fellowship Training, Experience, and Practice Characteristics. Spine Deform 2018; 6:60-66. [PMID: 29287819 DOI: 10.1016/j.jspd.2017.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/15/2017] [Accepted: 06/17/2017] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Survey study. OBJECTIVE The purpose of this paper was to assess the level of adult spine deformity (ASD) knowledge among orthopedic spine surgeons and identify areas for improvement in spine surgery training. SUMMARY OF BACKGROUND DATA ASD is increasingly encountered in spine surgery practice. While ASD knowledge among neurosurgeons has been evaluated, ASD knowledge among orthopedic spine surgeons has not previously been reported. METHODS A survey of orthopedic spine surgeon members of North American Spine Society (NASS) was conducted to assess level of spine surgery training, practice experience, and spinal deformity knowledge base. The survey used was previously completed by a group of neurologic surgeons with published results. The survey used 11 questions developed and agreed upon by experienced spinal deformity surgeons. RESULTS Complete responses were received from 413 orthopedic spine surgeons. The overall correct-answer rate was 69.0%. Surgeons in practice for less than 10 years had a higher correct-answer rate compared to those who have practiced for 10 years or more (74% vs. 67%; p = .000003). Surgeons with 75% or more of their practice dedicated to spine had a higher overall correct rate compared to surgeons whose practice is less than 75% spine (71% vs. 63%; p = .000029). Completion of spine fellowship was associated with a higher overall correct-answer rate compared to respondents who did not complete a spine fellowship (71% vs. 59%; p < .00001). CONCLUSIONS Completion of spine fellowship and having a dedicated spine surgery practice were significantly associated with improved performance on this ASD knowledge survey. Unlike neurosurgeons, orthopedic spine surgeons who have practiced for less than 10 years performed better than those who have practiced for more than 10 years. Ongoing emphasis on spine deformity education should be emphasized to improve adult spinal deformity knowledge base.
Collapse
Affiliation(s)
- Zachary J Grabel
- Department of Orthopaedics, Emory University School of Medicine, 1648 Pierce Dr NE, Atlanta, GA 30307, USA.
| | - Robert A Hart
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239-3098, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Ave, San Francisco, CA 94131, USA
| | - Sara Heejung Park
- Department of Orthopedics, Brown University, Providence, RI 02912, USA
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22903, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of Illinois at Chicago, 1835 W Polk St, Chicago, IL 60612, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22903, USA
| | - Michael P Kelly
- Department of Orthopaedics, Washington University St Louis, 1 Brookings Dr, St. Louis, MO 63130, USA
| | - J Mason DePasse
- Department of Orthopedics, Brown University, Providence, RI 02912, USA
| | - Munish C Gupta
- Department of Orthopaedics, Washington University St Louis, 1 Brookings Dr, St. Louis, MO 63130, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Ave, San Francisco, CA 94131, USA
| | - Alan H Daniels
- Department of Orthopedics, Brown University, Providence, RI 02912, USA
| |
Collapse
|
24
|
Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States. Spine (Phila Pa 1976) 2016; 41:978-986. [PMID: 26679881 DOI: 10.1097/brs.0000000000001396] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Electronic survey. OBJECTIVE To identify the surgical treatment patterns for low back pain (LBP), among U.S. spine surgeons. Specifically determine (1) differences in surgical treatment responses based on various demographic variables; (2) probability of disagreement based on surgeon subgroups. SUMMARY OF BACKGROUND DATA Multiple surgical and nonsurgical treatments exist for LBP. Without strong evidence or clear guidelines for the indications and optimal treatments, there is substantial variability in surgical treatments used. METHODS A total of 445 U.S. spine surgeons completed a survey of clinical and radiographic case scenarios on patients with mechanical LBP, no leg pain, and concordant discograms. Surgical treatment options included no surgery, anterior lumbar interbody fusion (ALIF), posterolateral fusion with pedicle screws, transforaminal/posterior lumbar interbody fusion (TLIF/PLIF), etc. Statistical significance was set at 0.01 to account for multiple comparisons. RESULTS There was substantial clinical equipoise (∼75% disagreement) among surgeons on the approach to treat patients with LBP. Disagreement was highest in the southwest and lowest in the Midwest (82% vs. 69%, respectively); there was significantly lower disagreement among those in academic practices versus those in private/hybrid practices (56% vs.79%, respectively). Those in academic practices had approximately four times greater odds of choosing no surgery as compared to those in hybrid and private practices, who were more likely to choose ALIF or PLIF/TLIF. Those with fellowship training had approximately two times greater odds of selecting no surgery and four times greater odds of selecting ALIF as compared to those without fellowship training who were more likely to select TLIF/PLIF. CONCLUSION Significant differences exist among U.S. spine surgeons in the treatment of LBP. These differences stem from geographical location of the practice, specialty, practice type, and fellowship training. Recognizing the substantial variability underlies the importance of additional studies aimed at identifying the proper indications and most cost-effective treatments for LBP. LEVEL OF EVIDENCE 3.
Collapse
|
25
|
Daniels AH, Ames CP, Garfin SR, Shaffrey CI, Riew KD, Smith JS, Anderson PA, Hart RA. Spine surgery training: is it time to consider categorical spine surgery residency? Spine J 2015; 15:1513-8. [PMID: 25442094 DOI: 10.1016/j.spinee.2014.08.452] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/17/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley Street. Providence, RI 02905, USA.
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave., Rm. M779, San Francisco, CA 94143, USA
| | - Steven R Garfin
- Department of Orthopaedic Surgery, University of California San Diego, Perlman Ambulatory Care Center, 9350 Campus Point Drive, La Jolla, CA 92037, USA
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia, P.O. Box 800386, Charlottesville, VA, 22908, USA
| | - K Daniel Riew
- Department of Orthopaedic Surgery, Washington University, Cervical Spine Institute. 4921 Parkview Place, A12, St. Louis, MO 63110, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, P.O. Box 800386, Charlottesville, VA, 22908, USA
| | - Paul A Anderson
- Department of Orthopaedic Surgery, University of Wisconsin, 1685 Highland Ave., UWMFCB - 6215, Madison, WI 53705, USA
| | - Robert A Hart
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
| |
Collapse
|
26
|
Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am 2014; 96:e196. [PMID: 25471922 DOI: 10.2106/jbjs.m.01562] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current spine surgeon training in the United States consists of either an orthopaedic or neurological surgery residency, followed by an optional spine surgery fellowship. Resident spine surgery procedure volume may vary between and within specialties. METHODS The Accreditation Council for Graduate Medical Education surgical case logs for graduating orthopaedic surgery and neurosurgery residents from 2009 to 2012 were examined and were compared for spine surgery resident experience. RESULTS The average number of reported spine surgery procedures performed during residency was 160.2 spine surgery procedures performed by orthopaedic surgery residents and 375.0 procedures performed by neurosurgery residents; the mean difference of 214.8 procedures (95% confidence interval, 196.3 to 231.7 procedures) was significant (p = 0.002). From 2009 to 2012, the average total spinal surgery procedures logged by orthopaedic surgery residents increased 24.3% from 141.1 to 175.4 procedures, and those logged by neurosurgery residents increased 6.5% from 367.9 to 391.8 procedures. There was a significant difference (p < 0.002) in the average number of spinal deformity procedures between graduating orthopaedic surgery residents (9.5 procedures) and graduating neurosurgery residents (2.0 procedures). There was substantial variability in spine surgery exposure within both specialties; when comparing the top 10% and bottom 10% of 2012 graduates for spinal instrumentation or arthrodesis procedures, there was a 13.1-fold difference for orthopaedic surgery residents and an 8.3-fold difference for neurosurgery residents. CONCLUSIONS Spine surgery procedure volumes in orthopaedic and neurosurgery residency training programs vary greatly both within and between specialties. Although orthopaedic surgery residents had an increase in the number of spine procedures that they performed from 2009 to 2012, they averaged less than half of the number of spine procedures performed by neurological surgery residents. However, orthopaedic surgery residents appear to have greater exposure to spinal deformity than neurosurgery residents. Furthermore, orthopaedic spine fellowship training provides additional spine surgery case exposure of approximately 300 to 500 procedures; thus, before entering independent practice, when compared with neurosurgery residents, most orthopaedic spine surgeons complete as many spinal procedures or more. Although case volume is not the sole determinant of surgical skills or clinical decision making, variability in spine surgery procedure volume does exist among residency programs in the United States.
Collapse
Affiliation(s)
- Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, 593 Eddy Street, Providence, RI 02903. E-mail address for A.H. Daniels:
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, P.O Box 800212, Charlottesville, VA 22908
| | - Robert A Hart
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Suite OP31, Portland, OR 97239
| |
Collapse
|
27
|
Tomlinson J, Khan A. Letter to the editor: Orthopaedic education in the United Kingdom. Clin Orthop Relat Res 2014; 472:3235-6. [PMID: 25080265 PMCID: PMC4160489 DOI: 10.1007/s11999-014-3830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 07/17/2014] [Indexed: 01/31/2023]
Affiliation(s)
- James Tomlinson
- Northern General Hospital, Herries Road, Sheffield, South Yorkshire, S36 9XY, UK,
| | | |
Collapse
|