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Orthopaedic Trauma Fellowships

DeLong, William, G, Jr

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

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 255-258
doi: 10.1097/01.blo.0000224063.39990.01
SECTION I: SYMPOSIUM III: Orthopaedic Fellowships
Free

From the Division of Orthopaedic Trauma, Temple University Health System, Philadelphia, PA.

Correspondence to: William G. DeLong, Jr, MD, Division of Orthopaedic Trauma, Temple University Health System, 5th Floor Outpatient Building, 3401 N. Broad St., Philadelphia, PA 19140. Phone 215-707-2111, E-mail: william.delong@tuhs.temple.edu.

As a prospective candidate for a Trauma Fellowship, there are several details about which you should inquire that will help you choose a fellowship wisely. The first criterion is that the institution should have at least two attendings specializing in orthopaedic traumatology. Ask about the “personality of the fracture”-the ineffable aspects of the injury that dictate treatment. What also matters is the personality of the surgeon. By that I do not mean how charming he or she is; rather, sometimes quirks of the surgeon taking care of the injury-experience, biases, habits-may also influence treatment. Until every clinical decision is dictated by Level I evidence, the practice style of your teacher will strongly influence your own practice. To help ensure that you are taught well, you need to see a variety of approaches. Make sure you are taught by at least two teachers.

Look for rapport between you and the attending staff. You should expect the trauma attendings to be your mentors for your entire professional life. Traumatologists benefit from having senior attending surgeons with whom they have an ongoing (career-long) dialogue about approaches to care. In the trauma bay, the pace is too fast to ask for assistance in the middle of the fray. Rather, a well taught traumatologist has a game plan for every contingency. This is a mindset that comes from good mentors and teachers.

Unlike the situation in some subspecialties, in trauma a fellow will not only tolerate but welcome residents on the service. Residents help distribute the work load and enhance your learning. In a well-designed service, the resident will present patients to the fellow, who in turn instructs the resident and reports to the attending. This allows the fellow a chance to exercise independent thought without excessive independent action. Even observing and correcting minor resident mistakes will go a long way to honing your own skills and preventing you from making these mistakes yourself.

As a board eligible orthopaedic surgeon, you should already be a sufficiently accomplished technician so you can teach junior residents how to perform some surgeries. Likewise, if there are senior level residents on the rotations, you can tackle some of the more complex cases together. I advise you to not exclude programs merely because there are senior level residents on the service. In my experience, the presence of fellows and senior level residents can be mutually beneficial.

Your fellowship year should offer you practical skills as well. You should refine your talents regarding straightforward cases-learning to nail a long bone elegantly-and gain mastery over harder cases. In that latter category, I place complex pelvic fractures, comminuted calcaneal fractures, and reconstructive procedures for malunions, nonunions and deformities. You should also become adept at managing the complications of traumatic injuries and their treatments. A good balance of cases therefore requires not only a busy emergency room but a robust referral practice. (In other words, if a program generates enough of its own complications for you to learn without the benefit of tertiary referrals, you have to wonder about the quality of care being delivered there.)

When you interview at a program you meet with the director of the surgical trauma service. A well integrated relationship with the general traumatologists is essential for efficient function by the orthopedic surgeon. One sign of a healthy relationship is the presence of a regular multidisciplinary conference to discuss patient care. When you visit, you may also want to ask about the relationship between the orthopaedic surgery trauma staff and the neurosurgeons regarding spine trauma. The amount of spine trauma cared for by the traumatologists varies by institution, and there is no “right answer” regarding this division of labor. (At Temple, we share the spine with neurosurgery fifty-fifty.) Still, you should know what you are getting into: if you want a full spine experience, some programs will not be for you.

Back in the “days of the giants,” as it was called, it was often said the only problem with taking calls every other night was that you missed half of the good cases. Now, we are in the era of the 80 hour work week, operating under the correct assumption that human beings cannot be mentally sharp without sleep. On the other hand, a lot of the good cases do come in at night. A fair balance, I believe, is for the fellow to take call approximately every third night and every third weekend. This call should be from home with a cadre of residents remaining in house as primary responders. Perhaps the best measure of whether the fellow's call is a quality educational experience is to see if the program can survive without a fellow on a given night. At Temple, there are some nights that both a resident and a fellow are on call and there are some nights that only a resident is on call. If the fellow's presence is optional in terms of the function of the service, it is likely that the fellow's participation is an educational one.

The ideal program should offer a significant amount of time in the OR, at least 3 days per week. The caseload should be somewhere between 300 to 400 for the year, mixing both acute and so-called cold trauma. The trauma service at Temple University Hospital has about a 25% penetrating and 75% blunt case mix. There is no golden ratio, but a complete absence of one category or another represents a deficiency. There are a significant number of nonunion cases referred into our center each year, along with acute “problem” fractures sent in by local colleagues. We also provide tertiary care for bone transport and traction osteogenesis. I mention this to remind the applicant to look past the pure numbers and ask, “What types of cases are being done?”

During the fellowship, you should also spend some time in office hours. This will allow you to observe your mentor's medical decision making and also give you a chance to see patients in followup. If all that counted was a perfect anatomic alignment on the post-operative radiograph, we would fillet open every fracture and put all the little pieces back together with as much metal as will fit. Of course, it's the final result, not the initial radiograph, that counts, which is why we do not broadly dissect every fracture. (In fact, for many fractures, we don't even operate at all.) The best way to keep your eye on the prize-functional restoration, not jigsaw puzzle completion-is to spend some time in the office.

One feature that you won't find at every program (but found here at Temple, among others) is that the trauma attendings maintain an elective practice, performing ligament reconstruction, arthroplasties and the like. The chance to engage in some general orthopaedic practice will help you maintain the skills that you have developed over the past five years. In my experience, performing primary joint replacements helps a traumatologist manage peri-prosthetic fractures, for example, so the benefits are not merely tangential.

In some ways, the orthopaedic traumatologist is a generalist: we operate all over the body. Still, fellowship is the first step on the path to becoming a specialist. You will become that specialist with the right training. As you look at programs, seek a good mentor, at a good institution, with an ample and diverse case load. The rest is up to you.

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© 2006 Lippincott Williams & Wilkins, Inc.