Recently, one of our fourth year orthopedic residents stopped by for advice regarding his quest of the best hand surgery fellowship. Specifically, he was most interested in programs that offered “some” shoulder experience and provided for me a list of fellowships that did just that. What did he view as what type, duration, and level of teaching of shoulder, he stated that this was less important than to do some cases that would permit him to expand his clinical practice. I was struck by the fact that some of the fellowships he listed were neither integrated with surgeons, whose specialty was around the shoulder, nor individuals contributing to the knowledge base of the specialty.
This gave me a cause to pause and consider more thoroughly the ongoing discussions surrounding the idea of a 2-year “upper extremity” fellowship. Are these discussions aimed at expanding the knowledge base and performance of those who will pursue a career in hand surgery or more based on response to the “market” of fellow applicants? Where does it put those trained in Plastic Surgery who intend to pursue a more traditional hand surgery practice (p.s. keep in mind that the current Presidents of both Hand Surgery Societies are Plastic Surgeons!)? Should these fellowships be an integrated 2-year program covering all aspects of the upper limb or sequential “standard hand fellowship” followed by a standalone shoulder fellowship? Who will provide funding, and will there be a need for yet another formal and distinct match?
There exist very valid reasons to question whether our traditional hand surgery fellowship provides sufficient exposure and knowledge for those residents who are graduating from contemporary training programs? Not only are we seeing the effects of mandated hour restrictions but, perhaps of equal impact, less and less work is done at night—a traditional wonderful opportunity to develop surgical skills involving hand trauma. This carries over to our fellows who similarly are less and less exposed to these same opportunities.
In addition, as Hand Fellowship programs expand their faculty, fellows may also have less exposure to the breadth of the specialty, as 1 or 2-month rotations with different surgeons may provide only a “hit or miss” exposure to traumatic and reconstructive problems as well as less opportunity to follow patients longitudinally. Replantations and microsurgical reconstructive cases are decreasing in many fellowships, and some fellows may miss these cases because of increased number of fellows with resultant less trauma call.
For these very reasons, our current 12-month experience may no longer be applicable because of changes in surgical experience, expanding knowledge base, and increasing technological advances. Furthermore, although perhaps a “pipe dream,” there are also valid reasons for considerations toward restructuring surgical training programs before the Fellowship. Should the Orthopedic or Plastic training be shortened with more emphasis on moving toward specialty training sooner? Should there be Hand Surgery Residencies?
I cannot offer solutions, but all these questions are worthy of further discussion by our specialty training programs and boards.