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Hand Fellowships

Boyer, Martin, Israel

Section Editor(s): Bernstein, Joseph MD, Guest Editor

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 227-231
doi: 10.1097/01.blo.0000229288.68356.8d
SECTION I: SYMPOSIUM III: Orthopaedic Fellowships
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From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Correspondence to: Martin Israel Boyer, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes Plaza, West Pavillion, St. Louis, MO 63110. Phone: 314-747-2813; Fax: 314-747-2599; E-mail: boyerm@msnotes.wustl.edu.

The goal of postgraduate training in hand surgery is to refine the knowledge, skills and attitudes introduced during residency training. Each program can be evaluated on the quality of knowledge transfer (ie, teaching), the opportunity to hone skills (clinical and operative material), and the environment in which the right attitudes can develop.

Hand surgery is a practical discipline and highly dependent on technical excellence in the operating room. As a trauma fellowship graduate, I believe (without disparaging my former colleagues) that hand surgeons almost never tolerate the degree of imprecision one is allowed when nailing a mid-shaft fracture of the femur. Likewise, nothing can replace a gentle touch when operating under the microscope. I mention this explicitly because a good fellowship acknowledges the central importance of the operating room and will offer you a plethora of worthwhile surgical experience.

The key question regarding the operative educational experience is: How many cases does the fellow perform while being monitored actively by the teaching staff surgeon? Watching others operate is not without redeeming features; however, it is no substitute for hands-on practical experience. Operating without supervision simply allows one to make the same mistakes again and again.

In a good fellowship you should become adept at the surgical treatment of traumatic conditions (such as fractures, tendon injuries, ligament tears, soft tissue trauma, nerve and vascular injuries) and non-traumatic conditions (such as infections, arthritis, nerve compression, contractures, and congenital deformity). You should also learn to master the post-traumatic reconstruction of bone, tendon, nerve and soft tissue injuries. Both open surgical technique and arthroscopic techniques are taught, as well as arthroplasty techniques and indications.

The presence of a well-defined academic curriculum is of high importance as well. Neither Journal Clubs nor year-round reviews of topics covered by the Selected Readings in Hand Surgery should be considered optional. In addition, active anatomic dissection of cadaver hand, wrist and forearm specimens serves a dual function: to familiarize the fellows with the interrelationships of the various anatomic structures, and to help in the development of dissection skills. Preparing prosections for the instruction of students and residents serves yet a third function: teaching didactic skills to the instructor.

Although hand surgery training focuses on the hand and wrist, the real subject of training also includes the forearm and elbow. Exposure to some elbow cases should be mandatory. It is well within the realm of the hand surgeon to take care of elbow fractures and dislocations, instability and stiffness of the elbow. In addition, arthroscopic surgery of the elbow and total elbow arthroplasty should be taught. If shoulder training is offered, be sure that you are accorded more than observer status.

Microsurgical training is mandatory in any well-rounded hand surgery fellowship. At the minimum, fellows should be sent to an intensive microsurgical training course either at their own institution or a well-established center. Learning to perform free tissue transfers for the coverage of soft-tissue defects and free fibular transfer for reconstruction of large osseous defects should also be part of the fellows' surgical training. Mastering these should improve your employment prospects after fellowship as well.

Several fellowship training programs (usually those with Shriners' Hospital for Children affiliations) offer rotations with exposure to the surgery of congenital hand deformities. These are fascinating cases. Nonetheless, it is unlikely that a fellow without special interest in deformity will perform these cases in practice, and therefore a program without such exposure should not necessarily be graded as deficient.

Regarding whether to seek an accredited program, I have only one word to say: mandatory. You cannot sit for the CAQ examination without completing an accredited fellowship, and that alone is enough reason. If you are not seeking a certificate, but rather just some additional exposure to hand surgery, you may simply begin independent practice and spend a few weeks as a visiting observer at a busy program, or take CME courses offered by the American Society for Surgery of the Hand, among others.

Adequate numbers of trauma cases in fellowship are necessary, both in terms of learning surgical decision making and technique. Of course, this could be excessive; gunshot wounds, hand pus, and nail bed injuries, for example, can get tedious after repeated exposure. When examining the trauma experience at a given program, ask how the cases are divided; at some institutions, the general trauma service may take care of true hand cases, while at others the plastic surgery service may be given the first opportunity to operate on soft tissue injuries. The essential features of balanced trauma exposure are reasonable frequency (no greater than one night in four) of on call duty, a mix of ordinary and complex cases, and a good working environment.

The efficiency of your teachers in their day to day practice is something to consider. Hand surgeons tend to see more patients and perform more surgical cases than most other orthopaedic surgeons. Infrastructure can therefore influence the fellows' satisfaction. If you are responsible for x-ray organization, chart preparation and answering requests for prescription refills, you are spending time that may be better devoted to surgery, patient care or reading. Furthermore, an efficient mentor ' s practice will serve as a model for your own. An expert cast technician in your mentor's practice is wonderful but they should be used as teachers, not as a worker in your employ.

One final thought: You don't have to mimic everything the fellowship director does. For instance, an attending with very soft surgical indications may be able to teach you a lot of technical tricks: there will be more cases to do, after all, if the threshold for operating is low. What matters most is the fellowship experience is balanced, offering ample opportunity to learn everything. You can learn tissue handling from one instructor, medical decision making from a second, office efficiency from a third, and approaches to research from a fourth. Hand surgery is a diverse field, and what you need from fellowship is the chance to acquire the knowledge, skills and attitudes to begin practice. Full mastery comes decades later.

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© 2006 Lippincott Williams & Wilkins, Inc.