e94(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Topics in Training ACGME Accreditation of Orthopaedic Surgery Subspecialty Fellowship Training Programs Alan H. Daniels, MD, Zachary Grabel, BS, and Christopher W. DiGiovanni, MD Investigation performed at the Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
Background: Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program, followed by optional subspecialty fellowship training. There is an increasing trend for trainees to complete at least one fellowship program following residency training, with approximately 90% of current trainees planning to complete a fellowship. The purpose of this investigation was to assess the overall variability of orthopaedic subspecialty fellowships in terms of characteristics, match process, and the tendency to be accredited by the Accreditation Council for Graduate Medical Education. Methods: Nine orthopaedic surgery subspecialties were assessed for their fellowship match program, their number of fellowship programs and positions in the match, and the number of programs and positions accredited by the Accreditation Council for Graduate Medical Education. Programs with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery were compared with programs without a Subspecialty Certificate. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 were performed. Results: Three separate matching programs are used by the nine subspecialties. Hand surgery utilizes the National Residents Matching Program, shoulder and elbow surgery utilizes the American Shoulder and Elbow Surgeons Fellowship Match, and the other seven subspecialties utilize the San Francisco Matching Program. In total, 478 fellowship programs were identified, representing 897 fellowship positions. The highest percentage of fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education was in orthopaedic sports medicine (93.1%), compared with the lowest percentage in foot and ankle orthopaedics (16.3%). A significantly higher percentage (p < 0.05) of fellowship programs accredited by the Accreditation Council for Graduate Medical Education were found for subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates (hand and sports) (87.9%) compared with subspecialties without Subspecialty Certificates (34.3%). Conclusions: There are more orthopaedic subspecialty fellowship positions available annually than there are graduating orthopaedic surgery residents. Three independent matching programs are currently being used by the nine orthopaedic continued
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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subspecialties. Subspecialties vary in the proportion of programs with Accreditation Council for Graduate Medical Education accreditation. Subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates have a significantly greater proportion of fellowship programs accredited by the Accreditation Council for Graduate Medical Education compared with those without Subspecialty Certificates.
Clinical Relevance: Orthopaedic subspecialty fellowship programs are rapidly becoming a perceived necessity as part of orthopaedic surgery training. Fellowships continue to vary in matching system and their accreditation characteristics.
Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program1, followed by optional subspecialty fellowship training. Traditional orthopaedic residency training has been designed to expose residents to all aspects of orthopaedic surgery and to prepare them for general orthopaedic practice1,2. Increasing subspecialization within the field, additional work-hour restrictions, and increased supervision requirements continue to alter the clinical experience of orthopaedic surgery residents3. These demands have increased and orthopaedic surgery’s body of knowledge and technical innovations have expanded rapidly. Fellowship training may therefore be evolving as a necessity to help trainees become competent independent surgeons. There is currently an increasing trend for trainees to pursue fellowship training, with approximately 90% of current orthopaedic surgery trainees planning to complete at least one fellowship4,5. A growing number of today’s trainees will complete two fellowships, commonly in related specialties such as hand surgery and shoulder and elbow surgery, orthopaedic sports medicine and shoulder and elbow surgery, orthopaedic sports medicine and foot and ankle orthopaedics, or musculoskeletal oncology and adult reconstructive orthopaedics. As spinal surgery techniques have continued to expand rapidly, there has also been an increasing trend of spine surgery trainees completing two spinal surgery fellowships, often with one fellowship emphasizing spinal deformity, pediatric spinal surgery, minimally invasive spine surgery, spine oncology, spine arthroplasty, cervical spine surgery, or spine trauma. All nine major orthopaedic subspecialties are currently using a match program. The orthopaedic fellowship match process is variable across subspecialties in the match program used, the required application materials, timing of applications, and proportion of fellowships accredited by the Accreditation Council for Graduate Medical Education (ACGME). Additionally, the fellowships vary in whether they provide trainees with attending privileges, a compensation structure, and a benefits package. To our knowledge, an assessment of the proportion of programs and positions with ACGME accreditation for each orthopaedic subspecialty has not previously been reported. We sought to examine the available subspecialty fellowships offered to orthopaedic surgery trainees and hypothesized that subspecialties with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery (ABOS) would have a significantly greater proportion of programs with ACGME accreditation compared with subspecialties without a Subspecialty Certificate.
Materials and Methods An assessment of current orthopaedic surgery subspecialty fellowships utilizing a search of match programs and subspecialty society web pages was performed 6 (Table I). Each subspecialty recognized by the ACGME (adult reconstructive orthopaedics, foot and ankle orthopaedics, hand surgery, musculoskeletal oncology, orthopaedic sports medicine, orthopaedic surgery of the spine, orthopaedic trauma, and pediatric orthopaedics) was assessed for the fellowship match program, number of fellowship programs in the match, number of fellowship positions in the match, number of ACGME-accredited programs, and the number of positions outside of the fellowship match. Shoulder and elbow surgery is not currently recognized by the ACGME as an independent subspecialty, but does have a match program, and thus was assessed for number of programs and positions in the match. Shoulder and elbow surgery programs with ACGME accreditation are currently accredited through the orthopaedic sports medicine or adult reconstructive orthopaedics pathway because of a current lack of ACGME requirements for shoulder and elbow surgery training, although graduates of these programs receive a diploma for shoulder and elbow surgery training. A handbook published by the American Academy of Orthopaedic Sur7 geons (AAOS) titled ‘‘Postgraduate Orthopaedic Fellowships 2013’’ was additionally utilized to examine fellowship program characteristics. Hand surgery and orthopaedic sports medicine have Subspecialty Certificates (formerly Certificate of Added Qualification [CAQ]) offered by the ABOS. Subspecialty Certificates are separate from subspecialty examinations offered for Maintenance of Certification (MOC), which are also offered by the ABOS. These
TABLE I Matching Program for Orthopaedic Subspecialties Orthopaedic Subspecialty
Match Program
Adult reconstructive orthopaedics
San Francisco Matching Program
Foot and ankle orthopaedics
San Francisco Matching Program
Hand surgery
National Residents Matching Program
Musculoskeletal oncology
San Francisco Matching Program
Orthopaedic sports medicine
San Francisco Matching Program
Orthopaedic surgery of the spine
San Francisco Matching Program
Orthopaedic trauma
San Francisco Matching Program
Pediatric orthopaedics
San Francisco Matching Program
Shoulder and elbow surgery
American Shoulder and Elbow Surgeons Fellowship Match
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TABLE II Total Number of Orthopaedic Surgery Fellowship Programs and ACGME-Certified Orthopaedic Fellowship Programs Orthopaedic Subspecialty
No. of Fellowship Programs in the Match
No. of ACGME-Certified Programs
102
95 (93.1%)
Orthopaedic sports medicine Hand surgery
80
65 (81.3%)
Musculoskeletal oncology
14
11 (78.6%)
Pediatric orthopaedics
42
25 (59.5%)
Adult reconstructive orthopaedics
53
21 (39.6%)
Orthopaedic surgery of the spine
60
18 (30.0%)
Orthopaedic trauma
56
10 (17.9%)
Foot and ankle orthopaedics
43
7 (16.3%)
Shoulder and elbow surgery* Total
28
—
478
252 (52.7%)
*This subspecialty is accredited by the ACGME under the classification of orthopaedic sports medicine or adult reconstructive orthopaedics.
two subspecialties (hand surgery and orthopaedic sports medicine) were compared with subspecialties without a Subspecialty Certificate for their percentage of ACGME-accredited programs. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 to determine significance were performed. This study was exempt from institutional review board approval.
Source of Funding No external funding was obtained in support of this study.
Results Adult reconstructive orthopaedics, musculoskeletal oncology, orthopaedic sports medicine, orthopaedic surgery of the spine, orthopaedic trauma, foot and ankle orthopaedics, and pediatric orthopaedics utilize the San Francisco Matching Program (https://sfmatch.org/). Hand surgery utilizes the National Residents Matching Program (http://www.nrmp.org/), and shoulder and elbow surgery utilizes the American Shoulder and Elbow
Surgeons Fellowship Match (http://www.ases-assn.org/?p=physicfellowships) (Table I). In total, 478 fellowship programs were identified and were composed of 897 fellowship positions (Tables II and III). The percentage of ACGME-accredited fellowship programs is 93.1% for orthopaedic sports medicine, 81.3% for hand surgery, 78.6% for musculoskeletal oncology, 59.5% for pediatric orthopaedics, 39.6% for adult reconstructive orthopaedics, 30.0% for orthopaedic surgery of the spine, 17.9% for orthopaedic trauma, and 16.3% for foot and ankle orthopaedics (Table II). Of the 897 fellowship positions offered in the subspecialty matches, 58.3% are from ACGME-accredited programs. The highest proportion of ACGME-accredited positions is in orthopaedic sports medicine (97.3%), and the lowest proportion is in orthopaedic trauma (20.5%).
TABLE III Orthopaedic Surgery Fellowship Positions Orthopaedic Subspecialty
No. of Fellowship Positions in Match
No. of ACGME-Accredited Fellowship Positions
Orthopaedic sports medicine
224
218 (97.3%)
Hand surgery
168
142 (84.5%)
66
39 (59.1%)
Adult reconstructive orthopaedics and musculoskeletal oncology
137*
52 (38.0%)
Orthopaedic surgery of the spine
Pediatric orthopaedics
112
35 (31.3%)
Foot and ankle orthopaedics
70
21 (30.0%)
Orthopaedic trauma
78
16 (20.5%)
Shoulder and elbow surgery†
42
—
897
523 (58.3%)
Total
*Adult reconstructive orthopaedics and musculoskeletal oncology are grouped together by the San Francisco Matching Program. †This subspecialty’s programs, which are accredited by the ACGME, are reported by the ACGME under the classification of orthopaedic sports medicine or adult reconstructive orthopaedics.
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A significantly greater proportion (p = 0.0447) of ACGMEaccredited fellowships was found for programs with a Subspecialty Certificate (hand surgery and orthopaedic sports medicine) (87.9%) compared with programs without a Subspecialty Certificate (34.3%). Discussion This study examined the match programs and ACGME accreditation status of fellowships in nine orthopaedic surgery subspecialties. There is variability in the percentage of fellowship programs that are accredited by the ACGME, with a significantly higher proportion of ACGME-accredited programs in subspecialties that have a Subspecialty Certificate offered by the ABOS. This is likely explained by the necessity of graduating from an ACGME-approved fellowship program to successfully obtain a Subspecialty Certificate. Currently, there are more fellowship positions offered in orthopaedic subspecialty match programs than the annual number of orthopaedic residency graduates. In 2013, there were 692 allopathic residency positions and 100 osteopathic residency positions offered; thus, the 897 fellowship positions offered in match programs are more numerous than residency positions. The surplus of fellowship positions allows for fellowship positions for international medical graduates and surgeons wishing to perform more than one subspecialty fellowship. Orthopaedic fellowships are being completed by a large majority of trainees in the United States. The reasons for the rapid expansion of orthopaedic fellowship training are numerous. Resident duty-hour restrictions have altered the experience of orthopaedic surgery trainees, and fellowship training may be required to become an independent and proficient orthopaedic surgeon3,8. Additionally, orthopaedic knowledge continues to grow, leading to new techniques and skills that surgeons must acquire to provide optimal patient care. This trend has led to additional subspecialization within the field, a trend that has been observed in general surgery, neurological surgery, urological surgery, and other surgical fields9-12. However, resident needs for additional training may not be the only reason for the expansion of fellowship training; training programs also benefit from the presence of fellows who may help compensate for manpower deficiencies due to resident duty-hour restrictions. ACGME accreditation may help define uniform standards for fellowship training, and although no direct evidence now exists to support ACGME accreditation’s effect on the quality of education, it has been suggested that subspecialty trainees from programs without ACGME accreditation may do more poorly on Part II of the ABOS examination4. Although Subspecialty Certificates in hand surgery and orthopaedic sports medicine require the completion of a one-year ACGME-accredited subspecialty fellowship, the theory that ACGME accreditation improves training programs is thus far unproven, and organizations such as the Orthopaedic Trauma Association are working on fellowship approval programs separate from ACGME accreditation13. It is also possible that ACGME approval actually impairs fellow education by inhibiting the transition to independence, although further study is needed to evaluate this assertion.
ACGME A C C R E D I TAT I O N O F O RT H O PA E D I C S U R G E RY S U B S P E C I A LT Y F E L LOW S H I P T R A I N I N G P R O G R A M S
There are several potential advantages and disadvantages to ACGME accreditation for fellowship programs. The possible benefits of ACGME accreditation include higher-quality applicants, improved reputation, and the ability for fellowship graduates in hand surgery and orthopaedic sports medicine to obtain a Subspecialty Certificate from the ABOS. The possible disadvantages of ACGME accreditation include duty-hour restrictions, intensive documentation and paperwork requirements, and comprehensive facility and faculty requirements, in addition to limitations in billing for clinical services due to Centers for Medicare & Medicaid Services regulations by ACGME-accredited fellows. The ability of fellows to gain staff privileges and to operate and bill independently depends on federal, state, local, and insurer regulations and may also affect the decision to pursue ACGME fellowship accreditation. In addition to variability in fellowship programs obtaining ACGME accreditation, this study found variability in the matching programs utilized by subspecialties. The San Francisco Matching Program, the American Shoulder and Elbow Surgeons Fellowship Match, and the National Residents Matching Program utilize different application and match dates and require somewhat different application materials. However, their match algorithms and application costs are similar. Prospective investigations into the effectiveness and satisfaction with each matching program may help to optimize the fellowship application process and may improve the overall process in the future. The trend toward orthopaedic subspecialty fellowship training is likely to continue because of ongoing and possible further increases in duty-hour and supervisory restrictions, paired with the expansion of orthopaedic surgery techniques. If additional subspecialties develop Subspecialty Certificates through the ABOS that require ACGME-accredited fellowship training, then ACGME accreditation will become more prevalent in those specialties as well. Future investigation should evaluate not only the effectiveness of fellowship training, but also the effects of ACGME accreditation and specific matching programs on fellowship effectiveness and satisfaction. Further standardization in fellowship training may improve trainee preparedness at the conclusion of training, although this assertion requires further examination. This study had several limitations. The fellowships examined in this investigation are in no way an exhaustive list: numerous fellowships exist that are not included in the match programs and are not listed on subspecialty web sites or in the AAOS handbook. Additionally, there are fellowships overseas, traveling fellowships, fellowships incorporated into residency training programs8, and unadvertised fellowship training experiences that orthopaedic trainees undertake. The number of fellowships described here represents an underestimate of the actual number of programs and positions. Thus, the percentage of ACGME-accredited programs is actually lower than our results indicate. However, determining the exact number of fellowships outside of the match is difficult because of the heterogeneity of the programs and the formation and loss of programs over time. A basic search of programs in the AAOS handbook that do not participate in the match, in addition to programs advertising on the Internet, reveals more than fifty additional
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fellowship programs not included in this investigation. These fellowships are heterogeneous, and many are unregulated by national organizations. This study examined the match programs and ACGME accreditation status of nine orthopaedic surgery subspecialties. Variability in matching program and the proportion of ACGME accreditation for fellowship programs was found, with more than 50% of current orthopaedic subspecialty fellowship programs having ACGME accreditation. The Subspecialty Certificate specialties of hand surgery and orthopaedic sports medicine have the highest proportion of ACGME-accredited fellowships. Further study is needed to investigate the effects of ACGME accreditation of fellowship training. n
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Alan H. Daniels, MD Zachary Grabel, BS Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. E-mail address for A.H. Daniels: [email protected] Christopher W. DiGiovanni, MD Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center for Outpatient Care, 3F, Suite 3300, 55 Fruit Street, Boston, MA 02114
References 1. ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery. 2013 Jul 1. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ 2013-PR-FAQ-PIF/260_orthopaedic_surgery_07012013.pdf. Accessed 2014 Mar 5. 2. Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education (ACGME) Orthopaedic Surgery Case Logs National Data Report. 2011. https://www.acgme.org/acgmeweb/Portals/0/PDFs/ ORSNatData1011.pdf. Accessed 2014 Mar 5. 3. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am. 2011 Dec 7;93(23):e1421-9. 4. Herkowitz HN, Connolly PJ, Gundry CR, Varlotta GP, Zdeblick TA, Truumees E. Resident and fellowship guidelines: educational guidelines for resident training in spinal surgery. Spine (Phila Pa 1976). 2000 Oct 15;25(20):2703-7. 5. American Medical Association. FREIDA Online. http://www.ama-assn.org/ama/ pub/education-careers/graduate-medical-education/freida-online.page. Accessed 2014 Mar 3. 6. Accreditation Council for Graduate Medical Education. www.acgme.org. 2013 Oct 4.
7. American Academy of Orthopaedic Surgeons. Postgraduate orthopaedic fellowships. 28th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2013. 8. Daniels AH, McDonnell M, Born CT, Hayda RA, Ehrlich MG, Trafton PG, Fischer SA, Digiovanni CW. Critical analysis of a trauma fellowship-modeled, six-year orthopaedic surgery training program. J Bone Joint Surg Am. 2013 Aug 7;95(15):e108. 9. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013 Apr;216(4):764-71; discussion 771–3. 10. Gormley EA. Career development resource: urology. Am J Surg. 2012 Jul; 204(1):135-7. 11. Mazzola CA, Lobel DA, Krishnamurthy S, Bloomgarden GM, Benzil DL. Efficacy of neurosurgery resident education in the new millennium: the 2008 Council of State Neurosurgical Societies post-residency survey results. Neurosurgery. 2010 Aug;67(2):225-32; discussion 232–3. 12. Toyota BD. Spinal subspecialization in post-graduate neurosurgical education. Can J Neurol Sci. 2004 May;31(2):204-7. 13. Orthopaedic Trauma Association. Fellowship Program Accreditation Requirements for the Orthopaedic Trauma Match. http://ota.org/media/110570/attorneyapproved-final-fellowship-accreditation-proposal.pdf. Accessed 2014 Mar 16.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Topics in Training ACGME Accreditation of Orthopaedic Surgery Subspecialty Fellowship Training Programs Alan H. Daniels, MD, Zachary Grabel, BS, and Christopher W. DiGiovanni, MD Investigation performed at the Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
Background: Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program, followed by optional subspecialty fellowship training. There is an increasing trend for trainees to complete at least one fellowship program following residency training, with approximately 90% of current trainees planning to complete a fellowship. The purpose of this investigation was to assess the overall variability of orthopaedic subspecialty fellowships in terms of characteristics, match process, and the tendency to be accredited by the Accreditation Council for Graduate Medical Education. Methods: Nine orthopaedic surgery subspecialties were assessed for their fellowship match program, their number of fellowship programs and positions in the match, and the number of programs and positions accredited by the Accreditation Council for Graduate Medical Education. Programs with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery were compared with programs without a Subspecialty Certificate. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 were performed. Results: Three separate matching programs are used by the nine subspecialties. Hand surgery utilizes the National Residents Matching Program, shoulder and elbow surgery utilizes the American Shoulder and Elbow Surgeons Fellowship Match, and the other seven subspecialties utilize the San Francisco Matching Program. In total, 478 fellowship programs were identified, representing 897 fellowship positions. The highest percentage of fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education was in orthopaedic sports medicine (93.1%), compared with the lowest percentage in foot and ankle orthopaedics (16.3%). A significantly higher percentage (p < 0.05) of fellowship programs accredited by the Accreditation Council for Graduate Medical Education were found for subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates (hand and sports) (87.9%) compared with subspecialties without Subspecialty Certificates (34.3%). Conclusions: There are more orthopaedic subspecialty fellowship positions available annually than there are graduating orthopaedic surgery residents. Three independent matching programs are currently being used by the nine orthopaedic continued
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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subspecialties. Subspecialties vary in the proportion of programs with Accreditation Council for Graduate Medical Education accreditation. Subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates have a significantly greater proportion of fellowship programs accredited by the Accreditation Council for Graduate Medical Education compared with those without Subspecialty Certificates.
Clinical Relevance: Orthopaedic subspecialty fellowship programs are rapidly becoming a perceived necessity as part of orthopaedic surgery training. Fellowships continue to vary in matching system and their accreditation characteristics.
Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program1, followed by optional subspecialty fellowship training. Traditional orthopaedic residency training has been designed to expose residents to all aspects of orthopaedic surgery and to prepare them for general orthopaedic practice1,2. Increasing subspecialization within the field, additional work-hour restrictions, and increased supervision requirements continue to alter the clinical experience of orthopaedic surgery residents3. These demands have increased and orthopaedic surgery’s body of knowledge and technical innovations have expanded rapidly. Fellowship training may therefore be evolving as a necessity to help trainees become competent independent surgeons. There is currently an increasing trend for trainees to pursue fellowship training, with approximately 90% of current orthopaedic surgery trainees planning to complete at least one fellowship4,5. A growing number of today’s trainees will complete two fellowships, commonly in related specialties such as hand surgery and shoulder and elbow surgery, orthopaedic sports medicine and shoulder and elbow surgery, orthopaedic sports medicine and foot and ankle orthopaedics, or musculoskeletal oncology and adult reconstructive orthopaedics. As spinal surgery techniques have continued to expand rapidly, there has also been an increasing trend of spine surgery trainees completing two spinal surgery fellowships, often with one fellowship emphasizing spinal deformity, pediatric spinal surgery, minimally invasive spine surgery, spine oncology, spine arthroplasty, cervical spine surgery, or spine trauma. All nine major orthopaedic subspecialties are currently using a match program. The orthopaedic fellowship match process is variable across subspecialties in the match program used, the required application materials, timing of applications, and proportion of fellowships accredited by the Accreditation Council for Graduate Medical Education (ACGME). Additionally, the fellowships vary in whether they provide trainees with attending privileges, a compensation structure, and a benefits package. To our knowledge, an assessment of the proportion of programs and positions with ACGME accreditation for each orthopaedic subspecialty has not previously been reported. We sought to examine the available subspecialty fellowships offered to orthopaedic surgery trainees and hypothesized that subspecialties with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery (ABOS) would have a significantly greater proportion of programs with ACGME accreditation compared with subspecialties without a Subspecialty Certificate.
Materials and Methods An assessment of current orthopaedic surgery subspecialty fellowships utilizing a search of match programs and subspecialty society web pages was performed 6 (Table I). Each subspecialty recognized by the ACGME (adult reconstructive orthopaedics, foot and ankle orthopaedics, hand surgery, musculoskeletal oncology, orthopaedic sports medicine, orthopaedic surgery of the spine, orthopaedic trauma, and pediatric orthopaedics) was assessed for the fellowship match program, number of fellowship programs in the match, number of fellowship positions in the match, number of ACGME-accredited programs, and the number of positions outside of the fellowship match. Shoulder and elbow surgery is not currently recognized by the ACGME as an independent subspecialty, but does have a match program, and thus was assessed for number of programs and positions in the match. Shoulder and elbow surgery programs with ACGME accreditation are currently accredited through the orthopaedic sports medicine or adult reconstructive orthopaedics pathway because of a current lack of ACGME requirements for shoulder and elbow surgery training, although graduates of these programs receive a diploma for shoulder and elbow surgery training. A handbook published by the American Academy of Orthopaedic Sur7 geons (AAOS) titled ‘‘Postgraduate Orthopaedic Fellowships 2013’’ was additionally utilized to examine fellowship program characteristics. Hand surgery and orthopaedic sports medicine have Subspecialty Certificates (formerly Certificate of Added Qualification [CAQ]) offered by the ABOS. Subspecialty Certificates are separate from subspecialty examinations offered for Maintenance of Certification (MOC), which are also offered by the ABOS. These
TABLE I Matching Program for Orthopaedic Subspecialties Orthopaedic Subspecialty
Match Program
Adult reconstructive orthopaedics
San Francisco Matching Program
Foot and ankle orthopaedics
San Francisco Matching Program
Hand surgery
National Residents Matching Program
Musculoskeletal oncology
San Francisco Matching Program
Orthopaedic sports medicine
San Francisco Matching Program
Orthopaedic surgery of the spine
San Francisco Matching Program
Orthopaedic trauma
San Francisco Matching Program
Pediatric orthopaedics
San Francisco Matching Program
Shoulder and elbow surgery
American Shoulder and Elbow Surgeons Fellowship Match
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TABLE II Total Number of Orthopaedic Surgery Fellowship Programs and ACGME-Certified Orthopaedic Fellowship Programs Orthopaedic Subspecialty
No. of Fellowship Programs in the Match
No. of ACGME-Certified Programs
102
95 (93.1%)
Orthopaedic sports medicine Hand surgery
80
65 (81.3%)
Musculoskeletal oncology
14
11 (78.6%)
Pediatric orthopaedics
42
25 (59.5%)
Adult reconstructive orthopaedics
53
21 (39.6%)
Orthopaedic surgery of the spine
60
18 (30.0%)
Orthopaedic trauma
56
10 (17.9%)
Foot and ankle orthopaedics
43
7 (16.3%)
Shoulder and elbow surgery* Total
28
—
478
252 (52.7%)
*This subspecialty is accredited by the ACGME under the classification of orthopaedic sports medicine or adult reconstructive orthopaedics.
two subspecialties (hand surgery and orthopaedic sports medicine) were compared with subspecialties without a Subspecialty Certificate for their percentage of ACGME-accredited programs. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 to determine significance were performed. This study was exempt from institutional review board approval.
Source of Funding No external funding was obtained in support of this study.
Results Adult reconstructive orthopaedics, musculoskeletal oncology, orthopaedic sports medicine, orthopaedic surgery of the spine, orthopaedic trauma, foot and ankle orthopaedics, and pediatric orthopaedics utilize the San Francisco Matching Program (https://sfmatch.org/). Hand surgery utilizes the National Residents Matching Program (http://www.nrmp.org/), and shoulder and elbow surgery utilizes the American Shoulder and Elbow
Surgeons Fellowship Match (http://www.ases-assn.org/?p=physicfellowships) (Table I). In total, 478 fellowship programs were identified and were composed of 897 fellowship positions (Tables II and III). The percentage of ACGME-accredited fellowship programs is 93.1% for orthopaedic sports medicine, 81.3% for hand surgery, 78.6% for musculoskeletal oncology, 59.5% for pediatric orthopaedics, 39.6% for adult reconstructive orthopaedics, 30.0% for orthopaedic surgery of the spine, 17.9% for orthopaedic trauma, and 16.3% for foot and ankle orthopaedics (Table II). Of the 897 fellowship positions offered in the subspecialty matches, 58.3% are from ACGME-accredited programs. The highest proportion of ACGME-accredited positions is in orthopaedic sports medicine (97.3%), and the lowest proportion is in orthopaedic trauma (20.5%).
TABLE III Orthopaedic Surgery Fellowship Positions Orthopaedic Subspecialty
No. of Fellowship Positions in Match
No. of ACGME-Accredited Fellowship Positions
Orthopaedic sports medicine
224
218 (97.3%)
Hand surgery
168
142 (84.5%)
66
39 (59.1%)
Adult reconstructive orthopaedics and musculoskeletal oncology
137*
52 (38.0%)
Orthopaedic surgery of the spine
Pediatric orthopaedics
112
35 (31.3%)
Foot and ankle orthopaedics
70
21 (30.0%)
Orthopaedic trauma
78
16 (20.5%)
Shoulder and elbow surgery†
42
—
897
523 (58.3%)
Total
*Adult reconstructive orthopaedics and musculoskeletal oncology are grouped together by the San Francisco Matching Program. †This subspecialty’s programs, which are accredited by the ACGME, are reported by the ACGME under the classification of orthopaedic sports medicine or adult reconstructive orthopaedics.
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A significantly greater proportion (p = 0.0447) of ACGMEaccredited fellowships was found for programs with a Subspecialty Certificate (hand surgery and orthopaedic sports medicine) (87.9%) compared with programs without a Subspecialty Certificate (34.3%). Discussion This study examined the match programs and ACGME accreditation status of fellowships in nine orthopaedic surgery subspecialties. There is variability in the percentage of fellowship programs that are accredited by the ACGME, with a significantly higher proportion of ACGME-accredited programs in subspecialties that have a Subspecialty Certificate offered by the ABOS. This is likely explained by the necessity of graduating from an ACGME-approved fellowship program to successfully obtain a Subspecialty Certificate. Currently, there are more fellowship positions offered in orthopaedic subspecialty match programs than the annual number of orthopaedic residency graduates. In 2013, there were 692 allopathic residency positions and 100 osteopathic residency positions offered; thus, the 897 fellowship positions offered in match programs are more numerous than residency positions. The surplus of fellowship positions allows for fellowship positions for international medical graduates and surgeons wishing to perform more than one subspecialty fellowship. Orthopaedic fellowships are being completed by a large majority of trainees in the United States. The reasons for the rapid expansion of orthopaedic fellowship training are numerous. Resident duty-hour restrictions have altered the experience of orthopaedic surgery trainees, and fellowship training may be required to become an independent and proficient orthopaedic surgeon3,8. Additionally, orthopaedic knowledge continues to grow, leading to new techniques and skills that surgeons must acquire to provide optimal patient care. This trend has led to additional subspecialization within the field, a trend that has been observed in general surgery, neurological surgery, urological surgery, and other surgical fields9-12. However, resident needs for additional training may not be the only reason for the expansion of fellowship training; training programs also benefit from the presence of fellows who may help compensate for manpower deficiencies due to resident duty-hour restrictions. ACGME accreditation may help define uniform standards for fellowship training, and although no direct evidence now exists to support ACGME accreditation’s effect on the quality of education, it has been suggested that subspecialty trainees from programs without ACGME accreditation may do more poorly on Part II of the ABOS examination4. Although Subspecialty Certificates in hand surgery and orthopaedic sports medicine require the completion of a one-year ACGME-accredited subspecialty fellowship, the theory that ACGME accreditation improves training programs is thus far unproven, and organizations such as the Orthopaedic Trauma Association are working on fellowship approval programs separate from ACGME accreditation13. It is also possible that ACGME approval actually impairs fellow education by inhibiting the transition to independence, although further study is needed to evaluate this assertion.
ACGME A C C R E D I TAT I O N O F O RT H O PA E D I C S U R G E RY S U B S P E C I A LT Y F E L LOW S H I P T R A I N I N G P R O G R A M S
There are several potential advantages and disadvantages to ACGME accreditation for fellowship programs. The possible benefits of ACGME accreditation include higher-quality applicants, improved reputation, and the ability for fellowship graduates in hand surgery and orthopaedic sports medicine to obtain a Subspecialty Certificate from the ABOS. The possible disadvantages of ACGME accreditation include duty-hour restrictions, intensive documentation and paperwork requirements, and comprehensive facility and faculty requirements, in addition to limitations in billing for clinical services due to Centers for Medicare & Medicaid Services regulations by ACGME-accredited fellows. The ability of fellows to gain staff privileges and to operate and bill independently depends on federal, state, local, and insurer regulations and may also affect the decision to pursue ACGME fellowship accreditation. In addition to variability in fellowship programs obtaining ACGME accreditation, this study found variability in the matching programs utilized by subspecialties. The San Francisco Matching Program, the American Shoulder and Elbow Surgeons Fellowship Match, and the National Residents Matching Program utilize different application and match dates and require somewhat different application materials. However, their match algorithms and application costs are similar. Prospective investigations into the effectiveness and satisfaction with each matching program may help to optimize the fellowship application process and may improve the overall process in the future. The trend toward orthopaedic subspecialty fellowship training is likely to continue because of ongoing and possible further increases in duty-hour and supervisory restrictions, paired with the expansion of orthopaedic surgery techniques. If additional subspecialties develop Subspecialty Certificates through the ABOS that require ACGME-accredited fellowship training, then ACGME accreditation will become more prevalent in those specialties as well. Future investigation should evaluate not only the effectiveness of fellowship training, but also the effects of ACGME accreditation and specific matching programs on fellowship effectiveness and satisfaction. Further standardization in fellowship training may improve trainee preparedness at the conclusion of training, although this assertion requires further examination. This study had several limitations. The fellowships examined in this investigation are in no way an exhaustive list: numerous fellowships exist that are not included in the match programs and are not listed on subspecialty web sites or in the AAOS handbook. Additionally, there are fellowships overseas, traveling fellowships, fellowships incorporated into residency training programs8, and unadvertised fellowship training experiences that orthopaedic trainees undertake. The number of fellowships described here represents an underestimate of the actual number of programs and positions. Thus, the percentage of ACGME-accredited programs is actually lower than our results indicate. However, determining the exact number of fellowships outside of the match is difficult because of the heterogeneity of the programs and the formation and loss of programs over time. A basic search of programs in the AAOS handbook that do not participate in the match, in addition to programs advertising on the Internet, reveals more than fifty additional
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fellowship programs not included in this investigation. These fellowships are heterogeneous, and many are unregulated by national organizations. This study examined the match programs and ACGME accreditation status of nine orthopaedic surgery subspecialties. Variability in matching program and the proportion of ACGME accreditation for fellowship programs was found, with more than 50% of current orthopaedic subspecialty fellowship programs having ACGME accreditation. The Subspecialty Certificate specialties of hand surgery and orthopaedic sports medicine have the highest proportion of ACGME-accredited fellowships. Further study is needed to investigate the effects of ACGME accreditation of fellowship training. n
ACGME A C C R E D I TAT I O N O F O RT H O PA E D I C S U R G E RY S U B S P E C I A LT Y F E L LOW S H I P T R A I N I N G P R O G R A M S
Alan H. Daniels, MD Zachary Grabel, BS Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. E-mail address for A.H. Daniels: [email protected] Christopher W. DiGiovanni, MD Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center for Outpatient Care, 3F, Suite 3300, 55 Fruit Street, Boston, MA 02114
References 1. ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery. 2013 Jul 1. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ 2013-PR-FAQ-PIF/260_orthopaedic_surgery_07012013.pdf. Accessed 2014 Mar 5. 2. Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education (ACGME) Orthopaedic Surgery Case Logs National Data Report. 2011. https://www.acgme.org/acgmeweb/Portals/0/PDFs/ ORSNatData1011.pdf. Accessed 2014 Mar 5. 3. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am. 2011 Dec 7;93(23):e1421-9. 4. Herkowitz HN, Connolly PJ, Gundry CR, Varlotta GP, Zdeblick TA, Truumees E. Resident and fellowship guidelines: educational guidelines for resident training in spinal surgery. Spine (Phila Pa 1976). 2000 Oct 15;25(20):2703-7. 5. American Medical Association. FREIDA Online. http://www.ama-assn.org/ama/ pub/education-careers/graduate-medical-education/freida-online.page. Accessed 2014 Mar 3. 6. Accreditation Council for Graduate Medical Education. www.acgme.org. 2013 Oct 4.
7. American Academy of Orthopaedic Surgeons. Postgraduate orthopaedic fellowships. 28th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2013. 8. Daniels AH, McDonnell M, Born CT, Hayda RA, Ehrlich MG, Trafton PG, Fischer SA, Digiovanni CW. Critical analysis of a trauma fellowship-modeled, six-year orthopaedic surgery training program. J Bone Joint Surg Am. 2013 Aug 7;95(15):e108. 9. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013 Apr;216(4):764-71; discussion 771–3. 10. Gormley EA. Career development resource: urology. Am J Surg. 2012 Jul; 204(1):135-7. 11. Mazzola CA, Lobel DA, Krishnamurthy S, Bloomgarden GM, Benzil DL. Efficacy of neurosurgery resident education in the new millennium: the 2008 Council of State Neurosurgical Societies post-residency survey results. Neurosurgery. 2010 Aug;67(2):225-32; discussion 232–3. 12. Toyota BD. Spinal subspecialization in post-graduate neurosurgical education. Can J Neurol Sci. 2004 May;31(2):204-7. 13. Orthopaedic Trauma Association. Fellowship Program Accreditation Requirements for the Orthopaedic Trauma Match. http://ota.org/media/110570/attorneyapproved-final-fellowship-accreditation-proposal.pdf. Accessed 2014 Mar 16.
