Future spine surgeons need fellowship training. Although there is no formal demand for such education-and there is no Certificate of Added Qualifications yet available for spine surgery-the complexity of the cases as well as the current marketplace make a spine fellowship a necessity, especially for those surgeons who plan on taking care of traumatic spine injuries. Even the best residency programs will most likely not leave you with enough competence and confidence to tackle the full gamut of spine conditions. In particular, if you are interested in an academic career in spine you will need to complete a fellowship. Thus, the first things to consider are your own motivation and career goals to ensure a spine fellowship is for you.
The most important factors to consider are the number of operative cases, the case mix, and the role of the fellow. The number of cases can be objectively measurable, and a quick glance at the number and types of cases can give you fairly good insight regarding the nature of the fellowship. As a broad rule of thumb, the surgical volume should be at least 250 cases for the year (per fellow). If it is less, you probably won't be operating enough. If the number is far greater, you may find other aspects of the fellowship, such as out-patient care, teaching, and research are deemphasized to the point your educational opportunities are compromised.
Although the number of cases per fellow is central, perhaps more important is the variety of those cases. The case mix can be broadly divided into adult and pediatric spine. Among adult cases, a useful classification comprises “classic” degenerative cases (lumbar stenosis); deformity cases (scoliosis, kyphosis); cervical cases, and trauma. Most fellowships provide a well-rounded experience in classic degenerative spine. Pay closer attention to the opportunities offered regarding cervical and deformity cases. Often a fellowship will have a weakness in one or the other.
Fellowships may vary quite a bit regarding exposure to spine trauma. Some fellowships have no acute trauma: the case mix is entirely elective. In other fellowships a large part of the case mix is generated from the emergency department. Even more variability is found among programs in the amount of pediatric and minimally invasive procedures performed. My own feeling is pediatric spine patients are often cared for by pediatric specialists, and minimally invasive procedures can be learned after fellowship (through coursework, for example) if the need arises. Good, solid education in the principles of spine surgery should prepare you to pick up additional skills even after your formal education is completed.
The number of cases and the case mix, however, are still not the end of the story. Find out who is indicating the patients for surgery, who is actually performing the procedures, and who is taking care of the patients postoperatively. The first and third questions are just as important as who is actually performing the surgery.
Another essential issue (and one that may be difficult to define) is the division of responsibility. What is the relationship between the attending, fellow, and resident for clinical and operative care of patients? Obviously, there has to be some flexibility but, in general, I would give extra points to those fellowship programs that have explicitly considered these questions and have an articulated policy. Having a policy not only helps prevent conflict between the fellow and the residents, it shows the fellowship director has considered this important question and is likely to have anticipated others.
Beyond case mix and the fellow's role, the presence of a “core curriculum” is crucial. The best programs will have a schedule of conferences and other, perhaps informal, teaching sessions to ensure in a given year there is a review of each of the major topics in the field. An example would be weekly conferences reviewing the “simple” as well the “complex” cases planned. In spine patients particularly, the indications for surgery and the type of procedure to be used once the necessity for surgery is established are least clear cut. Some of the greatest geographic variation in the rates of surgery is seen in the treatment of spinal diseases. Because of this lack of consensus, a core curriculum and informal teaching sessions are needed to establish a foundation for your own decision making once you are in practice.
In sum, all the best fellowships provide an adequate numbers of cases, a good distribution of pathology, apt participation by all members of the team and an explicit curriculum.
Once you have determined a fellowship meets these standards, there are still many factors to consider in deciding if a given fellowship is right for you. If you are interested in academics, you must consider the “tradition” (or, more to the point, the reputation) of the fellowship. There is no easy way of discerning the reputation of a fellowship. I suggest you approach your chairman (assuming he is not a spine surgeon) or some of the senior attendings and ask their opinion regarding the top spine programs. They may not know whether there are adequate numbers of cases, good distribution of pathology, and so forth, but they will have an overall sense of the program's reputation in the field.
For spine fellows, it is not the amount of on-call coverage that matters; it is the quality of the call. What you are required to do is far more important than how often you are asked to do it. For example, answering patient calls for more pain medication quickly ceases to be an educational experience. However, getting the chance to make medical decisions with supervision is exceptionally educational. If the on-call duty offers a quality experience, more frequent on-call duty is preferable.
The final factor to consider after having defined the best programs is what you can do to optimize your chances of obtaining a position. You must recognize that, as important as it is for you to enter a good program, it is just as important to the attendings they choose good applicants. All of us look good on paper; you cannot be admitted to an orthopaedic residency without an excellent record of performance. You must go beyond that, and give the fellowship program a strong sense of your worth not only on paper, but in person. The spine world is small, and it is almost assured somebody at your program knows someone at the program you would like to attend. At the least, schedule an informational interview with all attendings in your program who can recommend you. If you cannot find any connections between your home institution and the program(s) you want, it may be necessary to rotate at the program as a visitor. For better or worse, the reputation of your fellowship will be a strong influence on your career, and the extra effort you make while applying is highly likely to pay dividends.