Orthopedics

Feature Article 

Early Subspecialization in Orthopedic Surgery Training

J. Mason DePasse, MD; Michael I. Nzeogu, MD; Chris Travers, MD; Mary K. Mulcahey, MD; Mark A. Palumbo, MD; Robert A. Hart, MD; J. Lawrence Marsh, MD; Alan H. Daniels, MD

Abstract

Recent studies have shown that applicants to the American Board of Orthopaedic Surgery Part II examination are performing fewer procedures outside of their chosen subspecialty. In this study, the authors assessed whether trainees are beginning their subspecialization during residency. The authors reviewed the chosen fellowships and case logs of 231 residents graduating from 5 academic orthopedic residency training programs from 2002 to 2017. The number of cases logged by residents who chose a specialty was then compared with the number of cases logged by residents who chose other specialties. Residents who chose spine surgery (108.4±50.7 vs 74.4±60.2, P<.01), hand surgery (242.2±92.9 vs 194.3±78.2, P<.01), and sports medicine (278.5±105.8 vs 229.0±93.9, P<.01) performed significantly more procedures in their chosen fields than their colleagues. In contrast, for total joint arthroplasty (P=.18) and foot and ankle surgery (P=.46), there was no significant difference in the number of cases between residents who chose the sub-specialty and those who did not. Residents pursuing careers in spine surgery, hand surgery, and sports medicine obtained additional operative exposure to their chosen field during residency. Formalizing this early experience with specialization tracks during the chief year may be considered. [Orthopedics. 2019; 42(1):e39–e43.]

Abstract

Recent studies have shown that applicants to the American Board of Orthopaedic Surgery Part II examination are performing fewer procedures outside of their chosen subspecialty. In this study, the authors assessed whether trainees are beginning their subspecialization during residency. The authors reviewed the chosen fellowships and case logs of 231 residents graduating from 5 academic orthopedic residency training programs from 2002 to 2017. The number of cases logged by residents who chose a specialty was then compared with the number of cases logged by residents who chose other specialties. Residents who chose spine surgery (108.4±50.7 vs 74.4±60.2, P<.01), hand surgery (242.2±92.9 vs 194.3±78.2, P<.01), and sports medicine (278.5±105.8 vs 229.0±93.9, P<.01) performed significantly more procedures in their chosen fields than their colleagues. In contrast, for total joint arthroplasty (P=.18) and foot and ankle surgery (P=.46), there was no significant difference in the number of cases between residents who chose the sub-specialty and those who did not. Residents pursuing careers in spine surgery, hand surgery, and sports medicine obtained additional operative exposure to their chosen field during residency. Formalizing this early experience with specialization tracks during the chief year may be considered. [Orthopedics. 2019; 42(1):e39–e43.]

Orthopedic surgeons in the United States have increasingly become subspecialized.1,2 From 1990 to 2006, the proportion of practicing orthopedic generalists decreased from 44.2% to 28.7%.3 As of 2008, more than 90% of graduating residents were pursuing fellowship training,4 and a more recent study reported that the percentage of fellowship-trained applicants taking the American Board of Orthopaedic Surgery (ABOS) Part II examination increased from 76% to 90% from 2003 to 2013.2 The same study found that 78% of the procedures performed by all applicants were within their subspecialty, with that percentage increasing to 85% for applicants trained in hand or spine surgery.2

This increasing subspecialization in orthopedics may begin as early as residency training. Currently, the ABOS requirements for orthopedic training allow some flexibility for trainees to tailor their education to specific areas of interest, although these opportunities would likely require program approval.5 The ABOS specifies requirements for 12 months of adult orthopedics, 12 months of fractures and trauma, 6 months of pediatric orthopedics, and 6 months of basic or clinical specialties after the intern year.5 Thus, 12 months are left to the discretion of the programs. Furthermore, although the Accreditation Council for Graduate Medical Education specifies minimum case numbers for graduation, these minimum numbers are fairly small and would not interfere with resident subspecialization.6

Several studies of orthopedic resident case logs have shown dramatic variability in the number of procedures different residents perform in different fields.7–10 Daniels et al7 found a 5.5-fold difference between the top and bottom 10% of orthopedic residents in the number of spine procedures logged. Gil et al10 found a 5-fold difference in the number of shoulder arthroscopy procedures, a 3.4-fold difference in the number of knee arthroscopy procedures,10 and a 3.9-fold difference in the number of peripheral nerve procedures.8 Although some of this variability is likely due to differences in institutional case volume, it is possible that residents are using the freedom allowed by the ABOS and Accreditation Council for Graduate Medical Education requirements to acquire additional experience in their area of interest.

In this study, the authors used case log data from 5 large academic centers to determine whether resident interest in spine surgery, hand surgery, sports medicine, total joint arthroplasty, and foot and ankle surgery impacted case volume. The authors hypothesized that residents pursuing careers in these fields would have significantly increased associated case volume relative to their peers.

Materials and Methods

The chosen fellowships of all residents who graduated from the Brown University program from 2002 to 2016, the Drexel University program from 2005 to 2015, the University of Iowa program from 2009 to 2015, the Oregon Health Sciences University program from 2010 to 2015, and the Tufts University program from 2005 to 2015 were reviewed. Additionally, all current senior residents graduating from Brown University in 2017 were surveyed to determine their future subspecialty fellowship.

Accreditation Council for Graduate Medical Education case logs for all of these residents were then reviewed. Case logs were analyzed for the number of individual cases in spine surgery, hand surgery, sports medicine, total joint arthroplasty, and foot and ankle surgery, as the case log formats allow searching by these fields for all included years. The total number of cases was reported. Multiple procedure codes applied to a single case were not considered separate cases because residents differed substantially on how they logged cases with more than one Current Procedural Terminology code.

Spine cases included any procedure on the cervical, thoracic, or lumbar spine. Hand cases included any procedure on the hand, wrist, or forearm. Sports medicine cases were defined as any arthroscopic procedure on the shoulder or knee. Hip arthroscopy was not included because Accreditation Council for Graduate Medical Education case logs did not include codes for hip arthroscopy until 2012. Additionally, residents after 2012 reported small numbers of hip arthroscopy cases. Total joint arthroplasty cases included total hip replacements, total knee replacements, and hip and knee revisions. Foot and ankle cases included any procedure performed on the foot and ankle; nailing for tibia fractures was excluded.

For each subspecialty, the number of cases logged by residents who chose a fellowship in that subspecialty was compared with the number of cases logged by all residents who chose other subspecialties. Comparisons were made within graduating classes to control for year in training to reduce the effect of institutional variation during the course of the study. For each subspecialty, comparisons were made within each program and as a pooled total. Two-tailed Student';s t tests were performed with Excel (Microsoft Corporation, Redmond, Washington), with P<.05 being considered statistically significant.

Results

The case logs of 231 residents graduating from 5 different orthopedic residency programs from 2002 to 2017 were reviewed. In total, 50 (21.6%) chose sports medicine, 44 (19.0%) chose hand surgery, 26 (11.3%) chose foot and ankle surgery, 25 (10.8%) chose spine surgery, and 21 (9.1%) chose adult reconstruction for fellowship training.

The mean number of spine surgery, hand surgery, sports medicine, total joint arthroplasty, and foot/ankle cases were 83.0±59.6, 208.0±85.2, 244.6±100.1, 270.6±108.4, and 198.8±78.2, respectively.

For residents who chose spine surgery, the mean number of spine cases was 108.4±50.7, which was significantly greater than the mean number of spine cases for residents who did not choose spine surgery (74.4±60.2; 1.5-fold difference; P<.01) (Table 1). Although individually this difference in case numbers reached significance only at programs 1 and 5, residents who chose spine surgery at programs 2 and 4 also performed 1.5 or more times the number of spine procedures when compared with their colleagues (Table 1).

Case Comparisons for Spine Surgery

Table 1:

Case Comparisons for Spine Surgery

Similarly, for residents who chose hand surgery, the mean number of hand surgery cases was 242.2±92.9, which was significantly greater than the mean number of hand surgery cases for residents who did not choose hand surgery (194.3±78.2; 1.2-fold difference; P<.01) (Table 2). Residents who chose hand surgery performed more hand surgeries than their colleagues at all evaluated programs, although individually this was significant only at program 5 (Table 2).

Case Comparisons for Hand Surgery

Table 2:

Case Comparisons for Hand Surgery

For residents who chose sports medicine, the mean number of knee or shoulder arthroplasty cases was 278.5±105.8, which was significantly greater than the mean number of knee or shoulder arthroplasty cases for residents who did not choose sports medicine (229.0±93.9; 1.2-fold difference; P<.01) (Table 3). Residents only at programs 3 and 5 showed significant differences in case numbers between residents who chose sports medicine and those who did not, although residents at programs 1 and 2 who chose sports medicine logged more cases than their colleagues.

Case Comparisons for Sports Medicine

Table 3:

Case Comparisons for Sports Medicine

In contrast, the mean number of total joint arthroplasty cases for residents who chose adult reconstruction was 300.0±115.7, which was not significantly different from the mean number of cases for residents who did not choose total joint arthroplasty (260.7±105.1; 1.2-fold difference; P=.18) (Table 4). Residents at program 2 who chose total joint arthroplasty performed significantly more procedures than their colleagues (P=.02), but this difference did not occur at other programs. Of note, only 12 residents in the dataset at programs 1, 3, 4, and 5 chose total joint arthroplasty.

Case Comparisons for Total Joint Arthroplasty

Table 4:

Case Comparisons for Total Joint Arthroplasty

Similarly, for residents who chose foot and ankle surgery, the mean number of cases was 163.4±46.8, and the mean number of cases for residents who did not choose foot and ankle surgery was 164.5±51.4 (P=.46). There were no significant differences at any individual program.

A subanalysis was performed of the total joint arthroplasty data excluding program 5 because the residents at that program performed a mean of 546.0±80.0 total joint procedures, whereas the mean number of total joint procedures performed by all other residents was 241.6±58.9. Excluding the program 5 residents, the mean number of total joint cases for residents who chose adult reconstruction was 271.2±67.5, which was significantly greater than the mean number of total joint cases for residents who did not choose adult reconstruction (231.7±51.8; 1.2-fold difference; P=.03).

Discussion

Technological advancements and surgical innovations have rapidly broadened the range of approaches and procedures available to orthopedic surgeons. Recent studies have shown that orthopedic surgeons are both pursuing more subspecialty training and performing a higher percentage of procedures within their subspecialty.1,2 Still, the model for training surgeons has remained essentially unchanged for the past 30 years. This study revealed that orthopedic trainees who plan careers in spine surgery, hand surgery, and sports medicine are already seeking more subspecialty exposure during residency, and the analysis by individual program suggests that this early subspecialization is occurring across the country.

The reason for this self-selection within these subspecialties may reflect factors other than residents'; own self-assessments of their level of preparation. One possibility is that once residents have chosen their subspecialty, they may intentionally seek out those cases on the basis of personal interest. In addition, faculty may offer access to cases to residents with a demonstrated interest in their subspecialty. Further, co-residents entering other orthopedic subspecialties may be more willing to pass up spine, hand, or sports medicine cases.

Early subspecialization is not unique to orthopedic surgery; it has been increasingly formalized in general surgery and other surgical specialties.11,12 Although plastic surgery, vascular surgery, and cardiothoracic surgery traditionally followed most or all of a general surgery residency, integrated programs for all 3 specialties now exist in which residents train within the selected subspecialty for their entire residency.11 Additionally, the American Board of Surgery approved a flexibility in surgery training option in 2011 that allows general surgery residents 12 months of flexible rotations in residency to tailor their training to their subspecialty interest.12 For residents interested in truly general practice, particularly in rural communities, a training track focused on broad-based training was also developed.12

The question becomes: Is it possible to institute a well-designed, intentional early specialization in orthopedic residency training within the current regulations? Both the Accreditation Council for Graduate Medical Education and ABOS mandate 36 months of orthopedic surgery rotations in postgraduate years 2 to 5.5 The ABOS requirements further specify 12 months of adult orthopedics, 12 months of orthopedic trauma, 6 months of pediatric orthopedics, and 6 months of basic and/ or clinical specialties.5 Still, both sets of requirements leave 12 unspecified months to be used at the program';s discretion. These months could serve as a focused postgraduate year 5 specialty training year, with some ongoing general orthopedic training occurring concurrently.

Such a change is possible within the current requirement framework. However, it would necessitate extensive planning at the individual program level to accommodate resident service coverage and completion of all required rotations prior to postgraduate year 5. The specialized chief resident year would be designed to prepare trainees for subspecialty fellowship, with a comprehensive curriculum incorporating specialty-specific didactics and clinical rotations. Research rotations could additionally be included. Preparing for the year would require close mentorship from senior faculty at earlier stages in residency, and ongoing assessment of the year with follow-up survey data would be performed to determine its perceived utility by the trainees and fellowship directors.13 American Board of Orthopaedic Surgery Part I preparation and general orthopedic trauma call would also be continued to ensure that well-trained orthopedic surgeons would emerge from the year.

This study had several limitations. The data were limited to 5 centers and may not reflect the training environment nationwide. Furthermore, the sample sizes limited the impact of the analysis of individual programs, necessitating data pooling. The accuracy of the data also depended on the accuracy of the logging practices of the individual residents, which may have varied considerably. Thus, the data presented may not adequately reflect the true number of procedures performed. Case log data also did not account for the complexity of the procedures or outpatient experiences and did not allow for evaluation of residents who chose the subspecialties of trauma, shoulder and elbow surgery, pediatric orthopedics, and orthopedic oncology. Finally, it is possible that the fellowship training sought by the trainees did not reflect their actual practice. Despite these limitations, the data provide valuable insight into current orthopedic surgery training.

Conclusion

Orthopedic residents interested in spine surgery, hand surgery, and sports medicine are already tailoring their residency experience at an early stage in training. A specialized chief resident year incorporating a well-designed, specialty-specific curriculum may be considered to formalize this training. Further research is necessary to determine if the increase in cases results in better preparation for fellowship and beyond.

References

  1. Sarmiento A. Subspecialization in orthopaedics: has it been all for the better?J Bone Joint Surg Am.2003;85(2):369–373. doi:10.2106/00004623-200302000-00028 [CrossRef]
  2. Horst PK, Choo K, Bharucha N, Vail TP. Graduates of orthopaedic residency training are increasingly subspecialized: a review of the American Board of Orthopaedic Surgery Part II database. J Bone Joint Surg Am. 2015;97(10):869–875. doi:10.2106/JBJS.N.00995 [CrossRef]
  3. Gaskill T, Cook C, Nunley J, Mather RC. The financial impact of orthopaedic fellowship training. J Bone Joint Surg Am. 2009;91(7):1814–1821. doi:10.2106/JBJS.H.01139 [CrossRef]
  4. Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90(5):1143–1159. doi:10.2106/JBJS.G.01305 [CrossRef]
  5. Hurwitz SR. 2016 Rules and Procedures for Residency Education Part I and Part II Examinations, 2016. https://www.abos.org/media/13762/2016_rules_and_procedures_-_part_ii.pdf. Accessed May 10, 2017.
  6. Accreditation Council for Graduate Medical Education. Orthopaedic surgery minimum numbers: Review Committee for Orthopaedic Surgery. http://www.acgme.org/Portals/0/PFAssets/ProgramResources/260_ORS_Case_Log_Minimum_Numbers.pdf. Accessed May 1, 2017.
  7. 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(23):e196. doi:10.2106/JBJS.M.01562 [CrossRef]
  8. Gil JA, Daniels AH, Akelman E. Resident exposure to peripheral nerve surgical procedures during residency training [retracted in: J Grad Med Educ. 2016;8(5):645]. J Grad Med Educ. 2016;8(2):173–179. doi:10.4300/JGME-D-15-00318.1 [CrossRef]
  9. Gil JA, Daniels AH, Weiss A-PC. Variability in surgical case volume of orthopaedic surgery residents: 2007 to 2013. J Am Acad Orthop Surg. 2016;24(3):207–212. doi:10.5435/JAAOS-D-15-00461 [CrossRef]
  10. Gil JA, Waryasz GR, Owens BD, Daniels AH. Variability of arthroscopy case volume in orthopaedic surgery residency. Arthroscopy. 2016;32(5):892–897. doi:10.1016/j.arthro.2016.01.018 [CrossRef]
  11. Grant SB, Dixon JL, Glass NE, Sakran JV. Early surgical subspecialization: a new paradigm? Part I. Bull Am Coll Surg. 2013;98(8):38–42.
  12. Kulaylat AN, Zheng F, Kuy S, Bittner JG IV, . Early surgical subspecialization: a new paradigm. Part II. Interviews with leaders in surgical education. Bull Am Coll Surg. 2013;98(8):43–49.
  13. Daniels AH, McDonnell M, Born CT, et al. Critical analysis of a trauma fellowship-modeled, six-year orthopaedic surgery training program. J Bone Joint Surg Am. 2013;95(15):e108. doi:10.2106/JBJS.L.00988 [CrossRef]

Case Comparisons for Spine Surgery

ProgramNo. of Residents Who Chose Spine (% of Program)Mean±SDDifferenceP

No. of Cases for Residents Who Chose SpineNo. of Cases for Residents Who Chose Other Specialties
113 (15.3)76.3±28.845.7±17.61.7-fold<.01
24 (9.1)138.0±51.291.2±43.61.5-fold.16
32 (8.3)194.5±50.2223.0±39.3NA.59
42 (4.8)135.5±70.065.8±12.92.1-fold.40
54 (11.1)126.8±25.052.0±16.62.4-fold<.01
Pooled25108.4±50.774.4±60.21.5-fold<.01

Case Comparisons for Hand Surgery

ProgramNo. of Residents Who Chose Hand (% of Program)Mean±SDDifferenceP

No. of Cases for Residents Who Chose HandNo. of Cases for Residents Who Chose Other Specialties
119 (22.4)271.9±112.6231.2±95.61.2-fold.18
25 (11.4)245.6±71.2185.6±53.91.3-fold.14
33 (12.5)231.0±56.3195.6±45.61.2-fold.41
48 (19.0)159.6±73.9139.1±46.41.1-fold.48
59 (25.0)254.8±25.7177.7±36.31.4-fold<.01
Pooled44242.2±92.9194.3±78.21.2-fold<.01

Case Comparisons for Sports Medicine

ProgramNo. of Residents Who Chose Sports (% of Program)Mean±SDDifferenceP

No. of Cases for Residents Who Chose SportsNo. of Cases for Residents Who Chose Other Specialties
117 (20.0)290.6±66.4259.9±75.31.1-fold.13
28 (18.2)225.4±149.2204.3±156.21.1-fold.75
36 (25.0)314.3±58.1249.1±75.01.3-fold<.05
47 (16.7)170.4±56.4171.4±51.8NA.97
514 (38.9)332.8±108.4237.6±84.61.4-fold.01
Pooled52278.5±105.8229.0±93.91.2-fold<.01

Case Comparisons for Total Joint Arthroplasty

ProgramNo. of Residents Who Chose Joints (% of Program)Mean±SDDifferenceP

No. of Cases for Residents Who Chose JointsNo. of Cases for Residents Who Chose Other Specialties
16 (7.1)212.7±53.8199.0±42.3NA.58
29 (20.5)298.4±56.0242.7±48.01.2-fold.02
33 (12.5)313.3±68.9259.1±52.31.2-fold.31
41 (2.4)251.0±00.0286.4±34.8NANA
52 (5.6)574.0±140.0536.7±68.01.1-fold.78
Pooled21300.0±115.7260.7±105.11.2-fold.18
Authors

The authors are from the Department of Orthopaedics (JMD, MAP, AHD), Division of Spine Surgery, Alpert Medical School, Brown University, Providence, Rhode Island; the Department of Orthopaedics (MIN), Drexel University College of Medicine, Philadelphia, Pennsylvania; the Department of Orthopaedics (CT), Tufts University School of Medicine, Boston, Massachusetts; the Department of Orthopaedics (MKM), Tulane University School of Medicine, New Orleans, Louisiana; the Department of Orthopedics (RAH), Swedish Medical Center, Seattle, Washington; and the Department of Orthopaedics (JLM), University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Drs DePasse, Nzeogu, Travers, and Mulcahey have no relevant financial relationships to disclose. Dr Palumbo is a paid consultant for Stryker, Orthofix, Spineart, Globus, and DePuy and receives royalties from Spineart and Globus. Dr Hart is a paid consultant for Orthofix, Medtronic, and Globus and receives royalties from SeaSpine, Globus, and DePuy. Dr Marsh receives royalties from Biomet and Tornier and holds stock in FxRedux. Dr Daniels is a paid consultant for Stryker, Orthofix, Spineart, Globus, and DePuy; has received research support from Orthofix; and receives royalties from Globus.

Correspondence should be addressed to: J. Mason DePasse, MD, Department of Orthopaedics, Division of Spine Surgery, Alpert Medical School, Brown University, 100 Butler Dr, Providence, RI 02906 ( jmdepasse@gmail.com).

Received: December 20, 2017
Accepted: July 18, 2018
Posted Online: November 14, 2018

10.3928/01477447-20181109-01

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