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Shoulder and Elbow Fellowships

Iannotti, Joseph, P

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

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 241-243
doi: 10.1097/01.blo.0000224064.47614.b2
SECTION I: SYMPOSIUM III: Orthopaedic Fellowships

From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH.

Correspondence to: Joseph P. Iannotti, MD, PhD, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195. Phone: 216-445-5151; Fax: 216-445-6255; E-mail:

The primary aim of shoulder and elbow fellowship training is mastery of evaluation and management skills. Because a high level of proficiency requires advanced reading and (typically) involvement in research-related activities, the implicit goal of these fellowships is to create shoulder and elbow experts. Fellows, if they have invested their time wisely, will graduate with abilities far above those of the typical community orthopaedic surgeon.

The first criterion for evaluating a fellowship is the adequacy of the surgical training experience. A graduating fellow should master all types of rotator cuff repair; instability procedures; shoulder and elbow joint replacement; and fracture care, spanning bracing to arthroplasty.

The fellow should attain expert level proficiency with the arthroscope for both the shoulder and elbow. Although the jury is still out regarding arthroscopic (versus open) rotator cuff repair, the consensus of the field is that many cases (impingement and instability for example) can be treated with arthroscopic methods. A fellowship that emphasizes open treatment may be fine, so long as the mentors are not narrow-minded about what the rest of the world is doing-and offer training elsewhere (learning center courses, visiting rotations, etc).

If a given program does not cover the entire range of shoulder and elbow conditions and treatments it is, technically speaking, deficient; but that need not disqualify it from consideration. The fellow may have other opportunities for learning these techniques. But more to the point, no fellowship can teach you everything. The process of being an expert in shoulder and or elbow surgery requires life long learning. The best fellowships foster this mindset and cultivate the attitudes and skills necessary to achieve it.

Some shoulder and elbow fellowships are that in name only; that is, they are primarily shoulder programs with only minimal educational offerings regarding the elbow. There certainly is a role for such programs. For one thing, a fellow may wish to devote his or her future practice to the shoulder, and would not be at a disadvantage having only minimum exposure to fellowship level elbow training. In addition, a strong shoulder fellowship graduate will usually have no problem obtaining intensive elbow training at another program after completion of the shoulder fellowship, if desired.

Fellowship applicants can probably be divided broadly into two types: those interested in the upper extremity, and those with a sports medicine bent. Some applicants may wonder if they should apply for a sports or shoulder program. There is no pat answer. There are, of course, many sports medicine programs whose shoulder and elbow offerings are outstanding. In general, applicants should choose a dedicated shoulder and elbow fellowship if their interests lie more toward management of degenerative conditions and fractures of the shoulder; if they do not want to be distracted by caring for other joints such as the knee; or have a particular interest in revision procedures and operations on older patients with poor quality tissues. The answer ultimately comes down to the individual applicant's interests and the particulars of the program. As a department chairman, I would feel comfortable hiring someone as a shoulder surgeon who trained at a sports medicine program with an outstanding shoulder experience.

By definition, not all fellowships can be above average, and it might be asked, therefore, what characteristics (which can be discerned by the applicant) consign a program to the bottom half. For me, the red flag is a lack of introspective insight; that is, not being aware of the fellowship program's own inadequacies. As noted above, inadequacies in some areas are not disqualifying. Not recognizing these inadequacies and working to improve them, however, is a fatal flaw. Similarly, I would be wary of programs which approach shoulder and elbow care in an excessively dogmatic way. This may be inferred from a lack of diversity in approaches to care. For example there is more than one way to manage rotator cuff tears or traumatic instability and these diverse approaches need to be part of the training program.

A fellowship will no doubt be enhanced if there is an affiliation with a basic science researcher working on shoulder and elbow problems, but this is by no means required. More than anything, what a fellow needs is a set of teachers that maintain a skeptical attitude toward standard practice and are open to discuss what they don't know. In a good fellowship, the fellow and mentors encourage asking good questions, with an understanding that some of these questions do not have clearly defined answers-or, in some cases, any answer at all. A very good fellowship works toward answering these questions. This can be done through clinical research or comprehensive critical assessment literature reviews. Basic science is only one facet of the process of finding good answers.

Shoulder and elbow education may be variably represented at the various residency programs, and accordingly, some fellowship applicants may have had extensive prior experience and some not at all. Residents in the first category may find that a six month fellowship is enough to hone their surgical skills, whereas those in the second may find themselves of the steep part of the learning curve even at the end of their fellowships. That said, I do not think applicants should choose their fellowship based on what they learned (or did not learn) in residency. Becoming an expert takes many years-indeed, a lifetime of learning.

Approximately half of shoulder and elbow fellowships are not based at universities or tertiary care hospitals. Unlike some other fields, perhaps, absolutely top notch education can be had at a non-university program.

Because shoulder and elbow is a fairly new subspecialty-the American Shoulder and Elbow Surgeons organization was founded only 25 years ago-many of the founders of that Society and the pioneers of the field are still in active practice. Nevertheless, in recent years there has been great movement away from programs being identified with particular individuals. This of course does not mean that individuals are not important. The skills and attitudes you acquire in fellowship will be strongly influenced by your teachers. Above all, I would value a program where the teachers emphasize critical thinking, healthy skepticism of common knowledge, and willingness to ask and make a strong effort to answer questions through clinical and or basic science investigation.



© 2006 Lippincott Williams & Wilkins, Inc.