CLINICAL PERSPECTIVE
An American Society for Surgery of the Hand (ASSH) Task Force Report on Hand Surgery Subspecialty Certification and ASSH Membership Charles A. Goldfarb, MD, W. P. Andrew Lee, MD, Dawn Briskey, MNA, James P. Higgins, MD
A task force for the American Society for Surgery of the Hand (ASSH) recently investigated the practice patterns, board certification, subspecialty certification status, and ASSH membership of hand surgeons after completion of fellowship training. A total of 37% of the fellowship graduates from 2000 to 2006 had not attained subspecialty certification for a variety of reasons. A smaller group of fellowship graduates obtained the subspecialty certification but had not become Active Members of the ASSH. Efforts to strengthen the hand surgeon community and best serve our patients should focus on evolving patterns in post fellowship choices that reflect practice type choices and generational changes. (J Hand Surg Am. 2014;39(2):330e334. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Hand surgery, fellowship, board certification, American Society for Surgery of the Hand, Certification in the Subspecialty of Surgery of the Hand.
H
has experienced steady growth over the past 15 years, as evidenced by the increasing size of the American Society for Surgery of the Hand (ASSH). In addition, there has been a recent, notable growth in the number of hand surgery fellowship match applicants such that in recent years, up to 25% of these applicants have not secured a fellowship. This trend AND SURGERY AS A SUBSPECIALTY
From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO; the Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; the American Society for Surgery of the Hand, Chicago, IL; and the Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD. Received for publication July 5, 2013; accepted in revised form October 25, 2013. The authors give special thanks to Kevin Lutsky, MD, Katherine Au, MD, and A. Lee Osterman, MD, for their contribution to the manuscript. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Charles A. Goldfarb, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 Euclid Avenue, Campus Box 8233, Saint Louis, MO 63110; e-mail: [email protected]. 0363-5023/14/3902-0018$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.10.017
330
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
was noted by ASSH leadership, who felt it merited an assessment of the practice dynamic of our growing subspecialty society. In 2012, the ASSH Council created a task force to examine the career choices of surgeons completing hand surgery fellowship training. The impetus for the task force was a concern that a substantial number of hand surgery fellowship graduates were not pursuing hand surgery subspecialty certification and ASSH membership. The task force investigated the practice patterns, board certification, subspecialty certification status, and ASSH membership of hand fellowship graduates. Data were gathered from each hand surgery fellowship program, the Accreditation Council for Graduate Medical Education (ACGME), the National Residency Matching Program (NRMP), the American Medical Association, and the ASSH. The following report is an account of these findings with a detailed analysis of the professional pathway of the hand surgeon. We hope that the findings will serve as a springboard for discussion regarding the trends observed and the means by which the ASSH can best meet the changing dimensions of its membership.
331
ASSH TASK FORCE REPORT
TABLE 1. Hand Fellowship Programs, Positions, and Applicants, With Pathway Breakdown for Appointment Years 2013 and 2014 Appointment Year 2013 Total programs Total available Positions
2014
80
80
157
160
Applicants
203
205
Filled positions
153
154
Program Breakdown
65 Orthopaedic surgery
14 Plastic surgery
1 General surgery
67 Orthopaedic surgery
13 Plastic surgery
1 General surgery
Available positions
130
19
8
135
17
8
Filled positions
126
19
8
132
14
8
HAND SURGEON PROFESSIONAL PATHWAY Hand surgery fellowship training is 12 to 18 months of intensive study of the diseases, disorders, injuries, and birth anomalies of the upper extremity. It is a region-based fellowship focusing on the upper extremity, founded because of the complex interplay between the bones, joints, nerves, vessels, and soft tissues. Acceptance to fellowship is predicated upon the completion of an orthopedic, plastic surgery, or general surgery residency accredited by the ACGME, American Osteopathic Association, or Royal College of Physicians and Surgeons of Canada. Fellowship As of May 2013, there were 77 ACGME accredited hand surgery fellowship programs: 60 orthopedic, 16 plastic, and 1 general surgery program.1 Programs are categorized by the department in which the hand fellowship is sponsored in the home institution and the specialty board responsible for the program’s accreditation. However, in some cases these designations may belie a mixed (orthopedic, plastic, and general surgery) discipline of the faculty members of each program. This sometimes incomplete designation exists despite the nearly identical ACGME accreditation requirements, fellowship eligibility requirements, NRMP matching process, and accessibility to subsequent subspecialty certification. Of these 77 programs, 73 participate in the NRMP (Appendix A, available on the Journal’s Web site at www.jhandsurg.org). The official NRMP match results for appointment year 2013 listed 80 programs with 157 training positions. (Some programs are counted more than once if the program offers more than 1 fellowship differing by length: ie, 12 vs 18 mo.) The appointment year J Hand Surg Am.
r
2013 hand fellowship match demonstrated the highest percentage of positions filled with United States allopathic graduates, compared with all other fellowships run through the NRMP at 92%.2 The match data from appointment year 2014 were similar, with 80 programs and 160 training positions (Table 1). Historically, the NRMP hand surgery match has demonstrated a high but not universal participation rate by both hand surgery fellowship applicants and programs. The NRMP match data can therefore provide a good means of assessing the growth trends of the subspecialty as a whole. Close inspection of the data trends over the past decade has demonstrated an increasing popularity of the subspecialty, with each successive appointment year showing record high numbers of applicants for appointment years 2009 to 2014 (yearly applicants: 127, 150, 155, 179, 199, and 205). This trend has altered the previously balanced ratio of applicants to positions offered. Postfellowship course Upon completion of a hand surgery fellowship, physicians begin practice, and most will elect to become board certified through their primary training board. In orthopedic surgery, the American Board of Orthopedic Surgery (ABOS) provides board certification. It requires passing a written examination (taken immediately after residency completion and before beginning fellowship), completion of 22 months of active practice, and an oral examination based on surgical cases submitted by the candidate. The American Board of Plastic Surgery (ABPS) requires a similar path, with a comprehensive written examination followed by an oral examination consisting of both unknown cases and those selected from the candidate’s submitted case list. Vol. 39, February 2014
332
ASSH TASK FORCE REPORT
A fellowship-trained, board certified hand surgeon is eligible for the examination for Certification in the Subspecialty of Surgery of the Hand (CSSH) after maintaining an active hand surgery practice for at least 2 years in 1 location in the United States or Canada. The CSSH is a written test administered by the Joint Committee on Surgery of the Hand, from the American Boards of Orthopedic Surgery, Plastic Surgery, and Surgery. The CSSH has evolved as the common subspecialty certification examination supplanting the Certificate of Added Qualifications in Surgery of the Hand previously administered by the ABOS, the Certificate of Added Qualifications in Surgery of the Hand previously administered by the ABPS, and the Surgery of the Hand Certification previously administered by the American Board of Surgery. In addition to these requirements, the candidate must submit a list of 125 hand surgery cases during a consecutive 12-month period within the 2 years preceding application. The case total must match or exceed defined minimums from 5 of 9 categories: bone and joint (20 cases), nerve (20 cases), tendon and muscle (20 cases), skin and wound problems (14 cases), contracture and joint stiffness (10 cases), tumor (10 cases), congenital (3 cases), microvascular (3 case), and nonsurgical (4 cases). If candidates do not fulfill 6 of these 9 categories, they may petition their respective board for individual consideration. Once these criteria have been met, the candidate who passes this written examination is granted the CSSH, which is valid for 10 years and then requires recertification every 10 years. The ABOS, ABPS, and American Board of Surgery representatives on the Joint Committee for Surgery of the Hand agreed in 2013 to extend the 125-case collection period to 15 months (from 12 mo) and to decrease the category requirements from 6 to 5. Certain complex cases may qualify for up to 3 categories to fulfill the examination requirements. The American Osteopathic Board of Surgery administers its own version of the examination. Requirements, timing, and test administration are slightly different from the examination given by the other boards. American Society for Surgery of the Hand The ASSH is the largest American society for hand surgeons and affiliate members. Successful application for membership requires the hand surgeon to hold the CSSH, submit a case list of at least 125 hand surgery cases within a 12-month period, and submit letters of support from 3 current ASSH members. As J Hand Surg Am.
r
of May 2013, the total membership was 3,367, including 2,151 active members. ASSH MEMBERSHIP CAPTURE TASK FORCE The variety of reporting mechanisms of the subspecialty boards, certifying bodies, and professional societies presented a formidable challenge in collecting data on a broad cross-section of our subspecialty’s members. The task force gathered current data on hand surgery fellowships, including the ACGME status and NRMP participation of each. Online tools were employed including the Web sites of the ACGME, NRMP, American Medical Association,1e3 and ASSH.4 Web sites for each fellowship were used, as well as e-mail and telephone inquiries with fellowship program coordinators and directors when necessary. Data were requested on fellowship graduates from the years 2000 to 2010 from each fellowship. These compiled data were cross-referenced with internal data from the ASSH. In addition, we performed e-mail and telephone surveys of hand fellowship graduates who were not members of the ASSH. We found this cohort of surgeons to be diverse. Some were members of the American Association for Hand Surgery. Some were actively practicing hand surgery, and some had passed the CSSH whereas others had not. We aimed to better understand the professional pathways that led to the decisions to decline CSSH certification or ASSH membership. Hand fellowship graduates After completion of hand surgery fellowship, the practice of medicine does not require board certification and does not require additional certification in hand surgery. Nonetheless, most doctors and hand surgeons choose to become board certified, and many chose to pursue certification via completion of the CSSH. Appendix B (available on the Journal’s Web site at www.jhandsurg.org) provides the numbers of hand fellowship graduates and CSSH recipients over the years 2000 to 2010. The percentage of CSSH recipients was higher from 2000 to 2006 compared with the entire interval of 2000 to 2010 because it takes a minimum of 3 years (and typically longer) after fellowship to obtain the CSSH (see requirements above) (Table 2). The graduating years 2000 to 2006 were thought to reflect a group of hand surgeons who would demonstrate professional pathways given the ample duration of time permitted to obtain board certification, pass the CSSH, and join the ASSH (if so desired). Of the 687 graduates from 2000 to 2006, 431 (63%) passed the CSSH and 256 (37%) did not Vol. 39, February 2014
ASSH TASK FORCE REPORT
patterns. In addition, factors such as size of the fellowship program or university affiliation did not predict the likelihood of graduates to pursue the CSSH. Even the presence of previous ASSH presidents on the fellowship faculty did not generate a higher percentage of graduates obtaining the CSSH.
TABLE 2. Total Hand Fellowships Graduates and CSSH Recipients Between 2000 and 2010, and 2000 and 2006 2000e2010
2000e2006
Total hand fellowship graduates
1,229
687
Total recipients of the CSSH
623 (51%)
431 (63%)
pass the CSSH.5 This number includes those who never took the CSSH and those who failed the CSSH. Available data do not enable separate analysis of these 2 groups. FACTORS AFFECTING THE DECISION TO PURSUE THE CSSH Subspecialty background of the trainee Appendix B provides detailed data on the years 2000 to 2010 for all 3 training pathways. Forty-five general surgery graduates held the CSSH (50%), whereas 46 did not. A total of 462 orthopedic surgery graduates held the CSSH (59%), whereas 323 did not. One hundred eleven plastic surgery graduates hold the CSSH (54%), whereas 93 did not. There was no statistical difference between the groups, with a chisquare value of 3.76 (P ¼ .15) The appendix also includes 149 fellowship graduates of unknown parent specialty. These surgeons were often foreign medical graduates without United States board certification, but this list also includes graduates for whom data were incomplete. It is more accurate to consider only the years 2000 to 2006. There were 441 orthopedic surgeryetrained fellowship graduates, and 341 held the CSSH (77%). There were 119 plastic surgery fellowship graduates, and 66 held the CSSH (55%). This difference between the 2 paths was significant (P < .001). The issue of training pathway was explored comprehensively in a previous report, which documented the declining number of plastic surgeryetrained hand fellows, holders of the CSSH, and hand surgeons.6 Specific fellowship program We assessed graduates from all ACGME fellowship programs to detect potential relationships between fellowship program and the decision to pursue a CSSH. Although some fellowship programs graduate surgeons were more likely to obtain CSSH, there were no consistent trends or statistically significant J Hand Surg Am.
333
r
ASSH Considering only the years 2000 to 2006, 431 of the 687 hand surgery fellowship graduates held the CSSH, 366 of whom were current members of the ASSH. Thus, 85% of those obtaining the CSSH were ASSH members, whereas 53% of all graduates were ASSH members. Sixty-five hand fellowship graduates obtained the CSSH but were not current ASSH members. We performed a further assessment of the 65 fellowship graduates who passed the CSSH but did not become a member of the ASSH, to better understand their choices. There were 64 Medical Doctors and 1 Doctor of Osteopathy. Thirty-three had been previous candidate members of the ASSH. Thirty-eight were board certified by the ABOS, 22 by the ABPS, and 5 by the American Board of Surgery. The surgeons were of mixed practice types, including 14 in academic practice. These individuals were surveyed to understand why they had taken CSSH and had not pursued or maintained ASSH membership. We held e-mail or telephone discussions with half of this group. Additional information was obtained on the remaining surgeons via Internet search (with information on practice type, etc). The most common explanation by those directly contacted was that the ASSH application process was too burdensome. For many, it was simply 1 more time-consuming hurdle at a time when time, money, or interest, singularly or in combination, was lacking. Some cited specific criteria such as the annual meeting requirement (1 meeting during the 3 years before application) or the requirement of a character reference as obstacles. Meeting attendance was cited as difficult because of its cost, the time of year, and the time required away from practice. Some questioned the pertinence of membership, because those individuals did not think that membership in the ASSH provided any perceived advantage (competitive, educational, or otherwise). Further analysis of the 65 CSSH recipients who were not current members of the ASSH yielded 4 subgroups based on the current practice type (as assessed by direct conversation and Internet evaluation). The Vol. 39, February 2014
334
ASSH TASK FORCE REPORT
first group included 38 surgeons with a practice based primarily in hand surgery. Many use the ASSH for educational purposes. This group was a mix of private practice and academic surgeons. The second group included 7 orthopedic surgeons with a practice devoted to the entire upper extremity, particularly shoulder surgery. The third group was 17 plastic surgeons with a diverse general plastic surgery practice that perhaps included some hand surgery. The final group of 3 included surgeons either not in active practice or in a practice without a notable amount of hand surgery. Attempts were made to contact all 256 hand fellowship graduates from 2000 to 2006 who did not hold the CSSH and were not ASSH members. These individuals were difficult to locate, and ultimately we had direct communication with 22. This group of hand surgery fellowship graduates cited a variety of reasons for not pursuing the CSSH. Many had a limited number or a limited variety of hand surgery cases. They reported either performing fewer than 125 hand cases per year or a mix of cases that did not satisfy the 9 categories outlined in the CSSH application process. Many of these CSSH eligible surgeons demonstrated some misconceptions regarding the case category criteria. Some could have qualified for the CSSH based on satisfying 6 of the 9 categories. Many respondents also were unaware that the CSSH permits requests for special consideration given to applicants demonstrating difficulty with case requirements. Other respondents reported not qualifying for the CSSH based on their training background. These perceptions resulted in their failure to pursue the CSSH as an initial step toward ASSH membership. In conclusion, the popularity of hand surgery as a subspecialty is growing, as evidenced by the steady
J Hand Surg Am.
r
growth in membership of the ASSH and the dramatic recent increase of hand surgery fellowship match applicants. This ASSH Task Force investigated the practice patterns, board certification, subspecialty certification status, and ASSH membership of hand surgeons after completing hand fellowship training. A higher than expected 37% of the hand fellowship graduates from 2000 to 2006 do not hold CSSH for a variety of reasons, as outlined in this report. A smaller, but still notable, group of fellowship graduates obtained the CSSH but are not members of the ASSH. This group demonstrates wide practice variation, but more than half have a practice with hand surgery as the primary focus. To strengthen the hand surgeon community and best serve our patients, we should focus on the evolving patterns of postfellowship choices that reflect practice type choices and generational changes. These efforts include further education of trainees on the pathways to the CSSH and ASSH as well as a continuing assessment of the criteria for both. REFERENCES 1. Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/ads/public/reports/reportrun? reportid¼3¤tyear¼2012&academicyearid¼2012. Accessed May 1, 2013. 2. National Residency Matching Program. Available at: http://www. nrmp.org/data/resultsanddatasms2013.pdf. Accessed May 1, 2013. 3. American Medical Association. Available at: https://freida.ama-assn. org/freida/user/programsearchsubmitdispatch.do. Accessed May 1, 2013. 4. American Society for Surgery of the Hand. Available at: https:// portal.assh.org/custom/fellowshipprogramdirectorysearch.aspx. Accessed May 1, 2013. 5. American Board of Orthopaedic Surgery. Available at: http://www. abos.org. Accessed May 1, 2013. 6. Higgins JP. The diminishing presence of plastic surgeons in hand surgery: a critical analysis. Plast Reconstr Surg. 2010;125(1): 248e260.
Vol. 39, February 2014
An American Society for Surgery of the Hand (ASSH) Task Force Report on Hand Surgery Subspecialty Certification and ASSH Membership Charles A. Goldfarb, MD, W. P. Andrew Lee, MD, Dawn Briskey, MNA, James P. Higgins, MD
A task force for the American Society for Surgery of the Hand (ASSH) recently investigated the practice patterns, board certification, subspecialty certification status, and ASSH membership of hand surgeons after completion of fellowship training. A total of 37% of the fellowship graduates from 2000 to 2006 had not attained subspecialty certification for a variety of reasons. A smaller group of fellowship graduates obtained the subspecialty certification but had not become Active Members of the ASSH. Efforts to strengthen the hand surgeon community and best serve our patients should focus on evolving patterns in post fellowship choices that reflect practice type choices and generational changes. (J Hand Surg Am. 2014;39(2):330e334. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Hand surgery, fellowship, board certification, American Society for Surgery of the Hand, Certification in the Subspecialty of Surgery of the Hand.
H
has experienced steady growth over the past 15 years, as evidenced by the increasing size of the American Society for Surgery of the Hand (ASSH). In addition, there has been a recent, notable growth in the number of hand surgery fellowship match applicants such that in recent years, up to 25% of these applicants have not secured a fellowship. This trend AND SURGERY AS A SUBSPECIALTY
From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO; the Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; the American Society for Surgery of the Hand, Chicago, IL; and the Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD. Received for publication July 5, 2013; accepted in revised form October 25, 2013. The authors give special thanks to Kevin Lutsky, MD, Katherine Au, MD, and A. Lee Osterman, MD, for their contribution to the manuscript. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Charles A. Goldfarb, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 Euclid Avenue, Campus Box 8233, Saint Louis, MO 63110; e-mail: [email protected]. 0363-5023/14/3902-0018$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.10.017
330
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
was noted by ASSH leadership, who felt it merited an assessment of the practice dynamic of our growing subspecialty society. In 2012, the ASSH Council created a task force to examine the career choices of surgeons completing hand surgery fellowship training. The impetus for the task force was a concern that a substantial number of hand surgery fellowship graduates were not pursuing hand surgery subspecialty certification and ASSH membership. The task force investigated the practice patterns, board certification, subspecialty certification status, and ASSH membership of hand fellowship graduates. Data were gathered from each hand surgery fellowship program, the Accreditation Council for Graduate Medical Education (ACGME), the National Residency Matching Program (NRMP), the American Medical Association, and the ASSH. The following report is an account of these findings with a detailed analysis of the professional pathway of the hand surgeon. We hope that the findings will serve as a springboard for discussion regarding the trends observed and the means by which the ASSH can best meet the changing dimensions of its membership.
331
ASSH TASK FORCE REPORT
TABLE 1. Hand Fellowship Programs, Positions, and Applicants, With Pathway Breakdown for Appointment Years 2013 and 2014 Appointment Year 2013 Total programs Total available Positions
2014
80
80
157
160
Applicants
203
205
Filled positions
153
154
Program Breakdown
65 Orthopaedic surgery
14 Plastic surgery
1 General surgery
67 Orthopaedic surgery
13 Plastic surgery
1 General surgery
Available positions
130
19
8
135
17
8
Filled positions
126
19
8
132
14
8
HAND SURGEON PROFESSIONAL PATHWAY Hand surgery fellowship training is 12 to 18 months of intensive study of the diseases, disorders, injuries, and birth anomalies of the upper extremity. It is a region-based fellowship focusing on the upper extremity, founded because of the complex interplay between the bones, joints, nerves, vessels, and soft tissues. Acceptance to fellowship is predicated upon the completion of an orthopedic, plastic surgery, or general surgery residency accredited by the ACGME, American Osteopathic Association, or Royal College of Physicians and Surgeons of Canada. Fellowship As of May 2013, there were 77 ACGME accredited hand surgery fellowship programs: 60 orthopedic, 16 plastic, and 1 general surgery program.1 Programs are categorized by the department in which the hand fellowship is sponsored in the home institution and the specialty board responsible for the program’s accreditation. However, in some cases these designations may belie a mixed (orthopedic, plastic, and general surgery) discipline of the faculty members of each program. This sometimes incomplete designation exists despite the nearly identical ACGME accreditation requirements, fellowship eligibility requirements, NRMP matching process, and accessibility to subsequent subspecialty certification. Of these 77 programs, 73 participate in the NRMP (Appendix A, available on the Journal’s Web site at www.jhandsurg.org). The official NRMP match results for appointment year 2013 listed 80 programs with 157 training positions. (Some programs are counted more than once if the program offers more than 1 fellowship differing by length: ie, 12 vs 18 mo.) The appointment year J Hand Surg Am.
r
2013 hand fellowship match demonstrated the highest percentage of positions filled with United States allopathic graduates, compared with all other fellowships run through the NRMP at 92%.2 The match data from appointment year 2014 were similar, with 80 programs and 160 training positions (Table 1). Historically, the NRMP hand surgery match has demonstrated a high but not universal participation rate by both hand surgery fellowship applicants and programs. The NRMP match data can therefore provide a good means of assessing the growth trends of the subspecialty as a whole. Close inspection of the data trends over the past decade has demonstrated an increasing popularity of the subspecialty, with each successive appointment year showing record high numbers of applicants for appointment years 2009 to 2014 (yearly applicants: 127, 150, 155, 179, 199, and 205). This trend has altered the previously balanced ratio of applicants to positions offered. Postfellowship course Upon completion of a hand surgery fellowship, physicians begin practice, and most will elect to become board certified through their primary training board. In orthopedic surgery, the American Board of Orthopedic Surgery (ABOS) provides board certification. It requires passing a written examination (taken immediately after residency completion and before beginning fellowship), completion of 22 months of active practice, and an oral examination based on surgical cases submitted by the candidate. The American Board of Plastic Surgery (ABPS) requires a similar path, with a comprehensive written examination followed by an oral examination consisting of both unknown cases and those selected from the candidate’s submitted case list. Vol. 39, February 2014
332
ASSH TASK FORCE REPORT
A fellowship-trained, board certified hand surgeon is eligible for the examination for Certification in the Subspecialty of Surgery of the Hand (CSSH) after maintaining an active hand surgery practice for at least 2 years in 1 location in the United States or Canada. The CSSH is a written test administered by the Joint Committee on Surgery of the Hand, from the American Boards of Orthopedic Surgery, Plastic Surgery, and Surgery. The CSSH has evolved as the common subspecialty certification examination supplanting the Certificate of Added Qualifications in Surgery of the Hand previously administered by the ABOS, the Certificate of Added Qualifications in Surgery of the Hand previously administered by the ABPS, and the Surgery of the Hand Certification previously administered by the American Board of Surgery. In addition to these requirements, the candidate must submit a list of 125 hand surgery cases during a consecutive 12-month period within the 2 years preceding application. The case total must match or exceed defined minimums from 5 of 9 categories: bone and joint (20 cases), nerve (20 cases), tendon and muscle (20 cases), skin and wound problems (14 cases), contracture and joint stiffness (10 cases), tumor (10 cases), congenital (3 cases), microvascular (3 case), and nonsurgical (4 cases). If candidates do not fulfill 6 of these 9 categories, they may petition their respective board for individual consideration. Once these criteria have been met, the candidate who passes this written examination is granted the CSSH, which is valid for 10 years and then requires recertification every 10 years. The ABOS, ABPS, and American Board of Surgery representatives on the Joint Committee for Surgery of the Hand agreed in 2013 to extend the 125-case collection period to 15 months (from 12 mo) and to decrease the category requirements from 6 to 5. Certain complex cases may qualify for up to 3 categories to fulfill the examination requirements. The American Osteopathic Board of Surgery administers its own version of the examination. Requirements, timing, and test administration are slightly different from the examination given by the other boards. American Society for Surgery of the Hand The ASSH is the largest American society for hand surgeons and affiliate members. Successful application for membership requires the hand surgeon to hold the CSSH, submit a case list of at least 125 hand surgery cases within a 12-month period, and submit letters of support from 3 current ASSH members. As J Hand Surg Am.
r
of May 2013, the total membership was 3,367, including 2,151 active members. ASSH MEMBERSHIP CAPTURE TASK FORCE The variety of reporting mechanisms of the subspecialty boards, certifying bodies, and professional societies presented a formidable challenge in collecting data on a broad cross-section of our subspecialty’s members. The task force gathered current data on hand surgery fellowships, including the ACGME status and NRMP participation of each. Online tools were employed including the Web sites of the ACGME, NRMP, American Medical Association,1e3 and ASSH.4 Web sites for each fellowship were used, as well as e-mail and telephone inquiries with fellowship program coordinators and directors when necessary. Data were requested on fellowship graduates from the years 2000 to 2010 from each fellowship. These compiled data were cross-referenced with internal data from the ASSH. In addition, we performed e-mail and telephone surveys of hand fellowship graduates who were not members of the ASSH. We found this cohort of surgeons to be diverse. Some were members of the American Association for Hand Surgery. Some were actively practicing hand surgery, and some had passed the CSSH whereas others had not. We aimed to better understand the professional pathways that led to the decisions to decline CSSH certification or ASSH membership. Hand fellowship graduates After completion of hand surgery fellowship, the practice of medicine does not require board certification and does not require additional certification in hand surgery. Nonetheless, most doctors and hand surgeons choose to become board certified, and many chose to pursue certification via completion of the CSSH. Appendix B (available on the Journal’s Web site at www.jhandsurg.org) provides the numbers of hand fellowship graduates and CSSH recipients over the years 2000 to 2010. The percentage of CSSH recipients was higher from 2000 to 2006 compared with the entire interval of 2000 to 2010 because it takes a minimum of 3 years (and typically longer) after fellowship to obtain the CSSH (see requirements above) (Table 2). The graduating years 2000 to 2006 were thought to reflect a group of hand surgeons who would demonstrate professional pathways given the ample duration of time permitted to obtain board certification, pass the CSSH, and join the ASSH (if so desired). Of the 687 graduates from 2000 to 2006, 431 (63%) passed the CSSH and 256 (37%) did not Vol. 39, February 2014
ASSH TASK FORCE REPORT
patterns. In addition, factors such as size of the fellowship program or university affiliation did not predict the likelihood of graduates to pursue the CSSH. Even the presence of previous ASSH presidents on the fellowship faculty did not generate a higher percentage of graduates obtaining the CSSH.
TABLE 2. Total Hand Fellowships Graduates and CSSH Recipients Between 2000 and 2010, and 2000 and 2006 2000e2010
2000e2006
Total hand fellowship graduates
1,229
687
Total recipients of the CSSH
623 (51%)
431 (63%)
pass the CSSH.5 This number includes those who never took the CSSH and those who failed the CSSH. Available data do not enable separate analysis of these 2 groups. FACTORS AFFECTING THE DECISION TO PURSUE THE CSSH Subspecialty background of the trainee Appendix B provides detailed data on the years 2000 to 2010 for all 3 training pathways. Forty-five general surgery graduates held the CSSH (50%), whereas 46 did not. A total of 462 orthopedic surgery graduates held the CSSH (59%), whereas 323 did not. One hundred eleven plastic surgery graduates hold the CSSH (54%), whereas 93 did not. There was no statistical difference between the groups, with a chisquare value of 3.76 (P ¼ .15) The appendix also includes 149 fellowship graduates of unknown parent specialty. These surgeons were often foreign medical graduates without United States board certification, but this list also includes graduates for whom data were incomplete. It is more accurate to consider only the years 2000 to 2006. There were 441 orthopedic surgeryetrained fellowship graduates, and 341 held the CSSH (77%). There were 119 plastic surgery fellowship graduates, and 66 held the CSSH (55%). This difference between the 2 paths was significant (P < .001). The issue of training pathway was explored comprehensively in a previous report, which documented the declining number of plastic surgeryetrained hand fellows, holders of the CSSH, and hand surgeons.6 Specific fellowship program We assessed graduates from all ACGME fellowship programs to detect potential relationships between fellowship program and the decision to pursue a CSSH. Although some fellowship programs graduate surgeons were more likely to obtain CSSH, there were no consistent trends or statistically significant J Hand Surg Am.
333
r
ASSH Considering only the years 2000 to 2006, 431 of the 687 hand surgery fellowship graduates held the CSSH, 366 of whom were current members of the ASSH. Thus, 85% of those obtaining the CSSH were ASSH members, whereas 53% of all graduates were ASSH members. Sixty-five hand fellowship graduates obtained the CSSH but were not current ASSH members. We performed a further assessment of the 65 fellowship graduates who passed the CSSH but did not become a member of the ASSH, to better understand their choices. There were 64 Medical Doctors and 1 Doctor of Osteopathy. Thirty-three had been previous candidate members of the ASSH. Thirty-eight were board certified by the ABOS, 22 by the ABPS, and 5 by the American Board of Surgery. The surgeons were of mixed practice types, including 14 in academic practice. These individuals were surveyed to understand why they had taken CSSH and had not pursued or maintained ASSH membership. We held e-mail or telephone discussions with half of this group. Additional information was obtained on the remaining surgeons via Internet search (with information on practice type, etc). The most common explanation by those directly contacted was that the ASSH application process was too burdensome. For many, it was simply 1 more time-consuming hurdle at a time when time, money, or interest, singularly or in combination, was lacking. Some cited specific criteria such as the annual meeting requirement (1 meeting during the 3 years before application) or the requirement of a character reference as obstacles. Meeting attendance was cited as difficult because of its cost, the time of year, and the time required away from practice. Some questioned the pertinence of membership, because those individuals did not think that membership in the ASSH provided any perceived advantage (competitive, educational, or otherwise). Further analysis of the 65 CSSH recipients who were not current members of the ASSH yielded 4 subgroups based on the current practice type (as assessed by direct conversation and Internet evaluation). The Vol. 39, February 2014
334
ASSH TASK FORCE REPORT
first group included 38 surgeons with a practice based primarily in hand surgery. Many use the ASSH for educational purposes. This group was a mix of private practice and academic surgeons. The second group included 7 orthopedic surgeons with a practice devoted to the entire upper extremity, particularly shoulder surgery. The third group was 17 plastic surgeons with a diverse general plastic surgery practice that perhaps included some hand surgery. The final group of 3 included surgeons either not in active practice or in a practice without a notable amount of hand surgery. Attempts were made to contact all 256 hand fellowship graduates from 2000 to 2006 who did not hold the CSSH and were not ASSH members. These individuals were difficult to locate, and ultimately we had direct communication with 22. This group of hand surgery fellowship graduates cited a variety of reasons for not pursuing the CSSH. Many had a limited number or a limited variety of hand surgery cases. They reported either performing fewer than 125 hand cases per year or a mix of cases that did not satisfy the 9 categories outlined in the CSSH application process. Many of these CSSH eligible surgeons demonstrated some misconceptions regarding the case category criteria. Some could have qualified for the CSSH based on satisfying 6 of the 9 categories. Many respondents also were unaware that the CSSH permits requests for special consideration given to applicants demonstrating difficulty with case requirements. Other respondents reported not qualifying for the CSSH based on their training background. These perceptions resulted in their failure to pursue the CSSH as an initial step toward ASSH membership. In conclusion, the popularity of hand surgery as a subspecialty is growing, as evidenced by the steady
J Hand Surg Am.
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growth in membership of the ASSH and the dramatic recent increase of hand surgery fellowship match applicants. This ASSH Task Force investigated the practice patterns, board certification, subspecialty certification status, and ASSH membership of hand surgeons after completing hand fellowship training. A higher than expected 37% of the hand fellowship graduates from 2000 to 2006 do not hold CSSH for a variety of reasons, as outlined in this report. A smaller, but still notable, group of fellowship graduates obtained the CSSH but are not members of the ASSH. This group demonstrates wide practice variation, but more than half have a practice with hand surgery as the primary focus. To strengthen the hand surgeon community and best serve our patients, we should focus on the evolving patterns of postfellowship choices that reflect practice type choices and generational changes. These efforts include further education of trainees on the pathways to the CSSH and ASSH as well as a continuing assessment of the criteria for both. REFERENCES 1. Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/ads/public/reports/reportrun? reportid¼3¤tyear¼2012&academicyearid¼2012. Accessed May 1, 2013. 2. National Residency Matching Program. Available at: http://www. nrmp.org/data/resultsanddatasms2013.pdf. Accessed May 1, 2013. 3. American Medical Association. Available at: https://freida.ama-assn. org/freida/user/programsearchsubmitdispatch.do. Accessed May 1, 2013. 4. American Society for Surgery of the Hand. Available at: https:// portal.assh.org/custom/fellowshipprogramdirectorysearch.aspx. Accessed May 1, 2013. 5. American Board of Orthopaedic Surgery. Available at: http://www. abos.org. Accessed May 1, 2013. 6. Higgins JP. The diminishing presence of plastic surgeons in hand surgery: a critical analysis. Plast Reconstr Surg. 2010;125(1): 248e260.
Vol. 39, February 2014
