Subspecialty Training in Pediatric Orthopaedics

Recently there has been an increase in the number of pediatric orthopaedic surgeons subspecializing in different areas of pediatric orthopaedics. Raw data from the POSNA Practice Management Committee has shown that close to 30% of recent graduates from pediatric orthopaedic fellowship programs decide to do a second fellowship which could potentially dramatically change the way pediatric orthopaedics is practiced in the United States.We have interviewed three pediatric orthopaedic surgeons who have established subspecialty practices to seek their opinion in this recent trend. 

Interview with Ernest L. Sink, MD, Pediatric and adolescent hip specialist, Hospital for Special Surgery 

Q: What are your thoughts about the recent trend toward subspecialization in pediatric orthopaedics? Do you support that trend? 

A: I do support the trend. Many of the procedures that pediatric orthopaedists are performing are increasing in complexity and risk. Specialization will increase volume and surgeon proficiency/safety for these procedures. The majority of pediatric orthopaedic procedures do not require subspecialization. I believe it is beneficial for procedures such as VCR in the spine, Modified Dunn for SCFE, skeletally immature ACL, or revision clubfoot. For these procedures, volume and systems that go with subspecialization are better for patient care. Education and research also benefit from subspecialization. 
 

Q: What made you decide to subspecialize in an area of pediatric orthopaedics? 

A: It was a natural decision to continue to learn about the hip, for which I found I had the most interest. I had great mentors (Dr. Robert Eilert, Dr. Mark Erickson, and Dr. Dennis Wenger) who directed me toward subspecialization because they were able to help me identify and support my interest. I was fortunate to spend time with Dr. Millis and Professor Ganz who became mentors and role models. I had a true interest and enjoyment in the patients, pathology, and surgery of the hip, thus I followed my innate passion. 

Q: What do you see as the cause of the recent trend toward subspecialization in pediatric orthopaedics? 

A: I think it is a combination of surgeons finding enjoyment in specific pathologies and surgeries, mentorship, and development of complex procedures that require volume. At each academic center a specific surgeon(s) will develop their niche and increase their knowledge, research, and education regarding their subspecialization. 

Q: What percentage of your current practice is dedicated to general pediatric orthopaedics? 

A: 15-20 percent. 

Q: Do you have any comments that you would like to add? 

A: I believe that subspecialization is not necessary to have a successful and enjoyable pediatric orthopaedic practice. The type and location of the practice are factors that play a role in subspecialization. 
 

Interview with Young Jo Kim, MD, Pediatric and adolescent hip specialist, Boston Children’s Hospital 

Q: What are your thoughts about the recent trend toward subspecialization in pediatric orthopaedics? Do you support that trend? 

A: I think the trend toward specialization is natural as the treatment becomes more complex and technically demanding. I think in the future we will have specialization for certain regions, such as hip, that span from children to young adults. We will also have specialization in disease conditions such as neuromuscular disease where a 

more holistic approach is necessary. 

Q: What made you decide to subspecialize in an area of pediatric orthopaedics? 

A: I did it mostly because I enjoyed understanding disease processes and I very much enjoyed the people in pediatric orthopaedics. When I decided to go into pediatrics, it was definitely not a popular thing to do. Many of my co-residents questioned my choice. However, ultimately you have to do what you enjoy and it seemed to have worked out for me. 

Q: What do you see as the cause of
the recent trend toward subspecialization in pediatric orthopaedics? 

A: I think the technical demands are higher, especially in spine and hip. Also, I think there is a trend toward expanding pediatric orthopaedics into the adolescent and young adult age range; hence, you need to be familiar with the modern adult techniques. 

Q: What percentage of your current practice is dedicated to general pediatric orthopaedics? 

A: I still do quite a bit of trauma and some lower extremity deformity work. I would say about 30- 40% of my volume is considered general pediatric orthopaedics. 

Interview with Mininder Kocher, MD, Pediatric sports medicine specialist, Boston Children’s Hospital 

Q: What are your thoughts about the recent trend toward subspecialization in pediatric orthopaedics? Do you support that trend? 

A: When I trained in the 90s, it was unusual to have a subspecialty practice in pediatric orthopaedics. It is one of the great aspects of pediatric orthopaedics that you have the option of doing general pediatric orthopaedics versus subspecializing in one area. I think I support the trend because it gives more options to people interested in pediatric orthopaedics. 

Q: What made you decide to subspecialize in an area of pediatric orthopaedics? 

A: I had difficulty choosing between sports medicine and pediatrics fellowships during residency. Rotation at Boston Children’s Hospital made me like pediatrics but I also enjoyed arthroscopic procedures. After finishing my pediatric orthopaedic fellowship, my mentors encouraged me to train in sports medicine and start a pediatric sports medicine practice at Boston Children’s Hospital. 

Q: What do you see as the cause of the recent trend toward subspecialization in pediatric orthopaedics? 

A: I think we see that because people started doing two fellowships and this created a path for people with different interests. People have different orientations, some enjoy doing a variety of procedures and will get bored doing only a limited number of procedures. On the other hand, some people prefer to dig deep in one area and develop a subspecialty practice. Q: What percentage of your current practice is dedicated to general pediatric orthopaedics? 

A: The first five years of my practice was mostly general pediatric orthopaedics but now the majority of my practice is limited to pediatric sports medicine. I perform close to 650 surgeries a year. I see and treat some general pediatric orthopaedic pathologies in my sports practice (varus/valgus deformities). I also take call and perform emergent pediatric orthopaedic procedures. 

Q: Do you have any comments that you would like to add? 

A: This trend is good for pediatric orthopaedics since it gives interested people more options to choose from. I also treat college athletes and my partners with subspecialty practice in adolescent hip also treat young adults. This shows an expansion of what traditionally was considered as pediatric orthopaedics. 

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