Five Questions about Subspecialty Training

Q: In your 18 years as an educator, of both residents and fellows, has the interest in pediatric orthopaedic fellows pursuing secondary fellowships in subspecialties increased?

A: Without a doubt, the interest in subspecialty training and subspecialty practice has increased dramatically since I entered the field of pediatric orthopaedics inthe mid-90s. 20 years ago, we knew of only one true pediatric sports medicine surgeon (Lyle Micheli in Boston). There were several experts in pediatric hand, pediatric hip and pediatric spine, but the vast majority also practiced general pediatric orthopedic surgery and took general pediatric orthopedic surgery call for their institution. As the musculoskeletal care of children and adolescents rapidly migrated out of the community and into children’s hospitals, the orthopaedic surgeons at children’s hospitals have developed subspecialty expertise in order to build their practice and differentiate themselves from their partners. This has had a very positive effect in the growth of subspecialty knowledge and certain surgical skills, but a detrimental effect on the unity among pediatric orthopaedic surgeons in practice, and the abilityto create meaningful CME that is of interest to all pediatric orthopaedic surgeons.

Q: What secondary fellowships are being pursued most often?

A: Recently, Glotzbecker et al* completed a study of recent pediatric orthopaedic fellows. As part of the survey, they reported that 30% of pediatric orthopaedic fellows were pursuing a second fellowship, and the most common choice was spine, sports or hand.

Q: Do you think the growing interest in pediatric subspecialty training stems from a growing demand from the public for super-subspecialists or limitations in fellowship training as a result of duty hour restrictions?

A: Neither. I’ve discussed second fellowships with many residents, fellow applicants and young pediatric orthopaedists in practice. While some of the interestin the second fellowships results from a true passion for a particular area of pediatric orthopaedics (e.g. neuromuscular, hip, sports), in most cases the second fellowship is done to position the fellow as an expertin a subspecialty so that they will be an attractivehire. So, in a way, it comes down to geography. If the budding pediatric orthopaedist aspires to practice in an area dominated by a small group of general pediatric orthopaedists (common in less populous regions), a second fellowship is probably not necessary. However, if the young pediatric orthopaedists are interested in practicing at one of the very large pediatric orthopaedic centers, he or she will almost surely need subspecialty expertise to be of maximum value to the group and to best develop a robust practice in the future. Duty hour restrictions have impacted other fellowships, but not really pediatric orthopaedics. Because duty hour restrictions have compromised overall surgical caseloads in many residency programs, self-aware graduates will pursue fellowships in adult reconstruction or adult sports medicine in order tobe as well-trained for general orthopaedics as PGY5s used to be before the duty hour restrictions began. We don’t see this in pediatric orthopaedics, because it does not really prepare the fellow for general orthopaedic practice in the community.
 

Q: What is POSNA doing to help guide residents and fellows seeking advice regarding secondary subspecialty training? 

A: POSNA does not have a specific program, and that
is appropriate. The advice comes primarily from mentors, who can be sought at the resident or fellow’s program, or at the annual IPOS meeting. POSNA also just completed an extraordinary and comprehensive workforce assessment, led by Jeff Sawyer. Once this 

is published, current residents and fellows will have some outstanding current data available to make decisions. 

Q: From a planning/manpower perspective, how does the growing number of subspecialty providers effect access to care for more generalized pediatric conditions? 

A: We do not need to train pediatric orthopaedic surgeons to spend most of their week seeing non-operative conditions (in-toeing, etc.). It’s not a good use of someone with six years of surgical training. 

The best way to care for children and adolescents in the future is to take a group of pediatric orthopaedic surgeons and partner them with pediatric musculoskeletal primary care physicians. Surgeons 

climb a learning curve toward competence and then need a critical mass of procedures to gain excellence as their careers progress. Simple procedures (tendon lengthening or elbow pinning) can be done by all pediatric orthopaedists, but complex spine deformity, PAOs, microvascular surgery, etc. should concentrate with those pediatric orthopaedists who have gained expertise through training and practice. We should work toward a strategy where highly skilled pediatric orthopaedic surgeons are busy in the operating room most of the week, see mostly pre-and postop surgical patients in the clinic, and serve in the trauma call rotation; most routine non-operative care is provided by primary care musculoskeletal physicians. We would be best served to move closer to the model of cardiothoracic surgeons and cardiologists. We will always have job security because no one will invent a pill or genetic treatment to prevent a child from jumping on a trampoline. 

References: 

1. Glotzbecker MP, S.B., Fletcher ND, Larson N, Hydorn CR, Sawyer JR, What to Expect After Pediatric Orthopaedic Fellowship and Demand for their Services: A Survey of Fellowship Graduates (2012-13). Journal of Pediatric Orthopaedics, 2015. Accepted for Publication. 



 
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