Pediatric orthopaedic fellowships exist to train pediatric orthopaedic surgeons. The ideal fellowship is geared to prepare a surgeon for a full-time career taking caring of infants, children, and young adults with musculoskeletal conditions and not so much for rounding out the training of a general orthopaedic surgeon who wishes to broaden his or her skills. As such, a good fellowship offers a balance between general pediatric orthopaedic surgery and tertiary care.
Pediatric orthopaedic surgery itself is unofficially divided into subspecialties-much like adult orthopaedics-such that most programs will have at least one or two attendings, each of whom possesses special skills in at least one specific area of practice. When examining the various program options, it is important to ensure the areas that interest you are covered in the fellowship. Most programs will adequately address sports medicine, the hip, and the foot, while hand surgery, spine, and tumor may be lacking. Likewise, whether or not a program is affiliated with a level I pediatric trauma center can also influence the nature of your experience.
While having exposure to three or more attending pediatric orthopaedic surgeons definitely increases the depth and breadth of teaching during the fellowship, what is perhaps most important is the opportunity to have a one-on-one working relationship with at least one of them. To some extent, though, all orthopaedic surgery fellowships are inclined to foster a mentor relationship, but this idea is especially critical in pediatric orthopaedics. In a fairly small organization like the Pediatric Orthopaedic Society of North America (POSNA), for example, personal recommendations, introductions, and invitations to collaborate are essential.
The issue of residents competing for cases with fellows comes up in all fields in orthopaedic surgery, but may be especially important in pediatric orthopaedics, as there is a mandated requirement for pediatrics orthopaedic exposure in the American Board of Orthopaedic Surgery designated residency curriculum. This may create a relative glut of residents relative to the number of surgeries performed at some institutions. The volume of cases done by clinical fellows at The Children's Hospital of Philadelphia, my home institution, currently seems appropriate: the clinical fellows (concentrating on “fellow-level” cases, defined below) perform approximately 400 to 500 surgeries each year. This seems to leave them enough time for both meaningful outpatient work and academic endeavors. While this is not a magic number, it is hard to imagine that 100 cases would be enough, or that academic work could be accomplished if 1000 surgeries were performed.
At our institution, we abide by the philosophy that the fellow should have the opportunity to first assist on cases that are similar to the ones s/he will be performing as an attending surgeon. These include not only the more complex spine and tumor surgeries, but also the less complex surgeries, such as cerebral palsy, soft tissue lengthenings, etc. Residents second assist on those cases but take a more active role for surgeries that are more typical for a community orthopaedic surgeon, such as closed reduction and pinning of supracondylar fractures or in-situ screw fixation of a slipped capital femoral epiphysis, among others. For those general cases, the fellow may also still participate.
The pediatric orthopaedic fellowship with which I am affiliated is at a free-standing tertiary children ' s hospital, which is part of a regional pediatric health care system. This offers specific advantages for the fellow, particularly in both the expanse of talent on other pediatric services and the wealth of clinical material that is referred. At The Children ' s Hospital of Philadelphia, for example, there are multidisciplinary programs in cerebral palsy, muscle disorders, and spina bifida, to name some of the main neuromuscular programs. Our program is also closely affiliated with the University of Pennsylvania Department of Orthopaedic Surgery, based (literally) right next door. Thus, our fellows have a chance to attend the university grand rounds, in addition to both the adult and pediatric visiting professor presentations. The fellows also have an opportunity for collaboration and research between institutions. Therefore, I would advise applicants to consider those programs that are at a free-standing children's hospital, and give extra weight to those that are closely affiliated-geographically and philosophically-with a department of orthopaedic surgery.
One of the goals of most top programs is to train the next generation of academic leaders. A good program, therefore, will provide facilities, intellectual stimulation, and academic support to allow the fellows to become successful in research. What will vary, perhaps, is the quality and extent of support. Thus, you should begin your search by looking for programs where there is an attending that has clinical and research interests similar to your own. You will more easily accomplish things with attending support, and such collaboration will foster the mentoring relationship that is so essential for a successful year. I would then pay particular attention to those programs with good financial resources and a robust database of past patients: both will be needed if you want to convert an idea into a paper in less than one year.
The fellows at our institution are not required to take routine night call. Our philosophy is that although on-call duties are educational, it is more important for the fellow to have the opportunity to read, study, and publish without having to carry the burden of night call responsibilities.
What is essential, however, is that the fellows have access to trauma cases. These can include patients who are admitted for surgery the next day or referred in from outside hospitals.
Pediatric orthopaedic surgery fellows must participate fully in the nonoperative and postoperative care of hospital patients. The ideal arrangement, I believe, is when this work is done in conjunction with the residents, so the fellow can learn by teaching. Along those lines, a good program will also have formal teaching requirements for fellows. At our institution, the fellows are in charge of the surgical indications conference, case presentations, the morbidity and mortality conferences, and the tumor board presentations.
Furthermore, outpatient work is also central. The fellow must be exposed to a general pediatric orthopaedic surgery clinic (concentrating primarily on injuries); specialty clinics within pediatric orthopaedics addressing problems including club foot, hip disorders, and spinal deformity; and multi-specialty clinics such as those for cerebral palsy.
Finally, I would also not overlook the small things. Since pediatric orthopaedic surgery involves substantial fracture care, a talented cast technician and a top flight radiology system go a long way toward making your life simpler, as well as allowing you to concentrate on your education. Remember: education is the first, last, and main goal.
© 2006 Lippincott Williams & Wilkins, Inc.