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Trends in Leadership at Spine Surgery Fellowships

Donnally, Chester J. III MD; Schiller, Nicholas C. MS; Butler, Alexander J. MD; Sama, Andrew J. BA; Bondar, Kevin J. BS; Goz, Vadim MD; Shenoy, Kartik MD; Vaccaro, Alexander R. MD, MBA, PhD; Hilibrand, Alan S. MD

Author Information
doi: 10.1097/BRS.0000000000003350
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The emergence of leaders and their influence defines the course of every professional field. In medicine, these pursuits influence physicians’ careers and serve as one metric of their professional success. Some physicians strive to fill roles as leaders in their practice, department, research communities both institutionally and nationally, professional academic societies, and academic programs. These highly influential and coveted positions tend to be filled by individuals uniquely qualified with a particular and broad set of skills necessary to fulfill the responsibilities associated with them. However, objective determinations as to what distinguishes a physician to be qualified for a particular leadership position seem vague. Specifically, in the field of orthopedic surgery there exists a lack of insight available to aid trainees and young physicians who aspire to achieve leadership roles. Our group sought to investigate this landscape within the field of spine surgery.

Recently, studies of the professional landscape of orthopedic surgery have explored a variety of insightful topics. These focusses range from the selection criteria for medical students and residents choosing orthopedic surgery as a specialty and exploring potential programs for training, to the evaluation guidelines that residency and fellowship directors utilized to select strong applicants.1–7 Additionally, some studies have discussed the skills and leadership training required to become a physician leader in surgical fields.8–11 One such paper attempted to correlate previous general surgery residency rank lists to academic career paths.12 Other studies discuss the discrepancy among the sex and cultural representation and the resulting leadership in the orthopedics and the implications that it may have.13–16 While prior descriptions of leadership trends within the field of plastic surgery has been published,17 no investigations focusing on the leadership trends among orthopedics surgery training programs has been described.

Recognizing the impact these leadership positions for the development of trainees and future research output, it is pivotal to understand the common factors that have allowed these individuals to ascend to and succeed in their current roles. The demographics and academic backgrounds of the current leaders of spine surgery training programs are discussed in this review to serve as a guide for other programs and those seeking leadership roles.


Data Collection

The Spine Fellowship Directory of the North American Spine Society (NASS) for 2019 to 2020 was utilized in order to incorporate all spine surgery fellowships in the United States. All listed fellowship directors (FDs), co-fellowship directors (co-FDs), and other fellowship leaders (FL) with established leadership roles within each fellowship program were identified. The demographic and educational background data for each FD were gathered via author review of up to date curriculum vitarum (CVs). Any information that was unavailable on CV review was gathered from institutional biographies, Web of Science, and emailed questionnaires sent to fellowship administrators and were followed up with phone call. The demographic information of interest included: age, sex, past residency and fellowship training, time since residency and fellowship completion until FD appointment, length in FD role, individuals research the Scopus H-index, and leadership in the major spine societies.

In order to obtain the individual Scopus H-index for each FD, the Scopus database (Elsevier BV, Waltham, MA) was subsequently queried to access their research specific information. The Scopus database has a search engine feature that operates the most extensive repository of peer-reviewed scientific literature with a citation tracking component. Scopus was employed to retrieve the H-index for every FD in the study.

Leadership roles from three major spine societies were also examined. The North American Spine Society (NASS), Cervical Spine Research Society (CSRS), and Scoliosis Research Society (SRS) were included due to their track record of influence on the field. Past leadership of these major spine societies was obtained by contacting the societies directly to determine current and past leaders. Presidency of the three major spine societies for at least a 1-year term during the period of 2003 to 2019 was included.

All collected data were then reviewed and verified by the lead author (C.J.D.) and cross-referenced with the FD directory to ensure accuracy.

Statistical Analyses

The following data points were gathered for each fellowship leader (FL): current institution, number of years in current role, leadership in CRS, leadership in SRS, leadership in NASS, specific role, age, name of residency institution and year of graduation, name of fellowship institution and year of graduation, name of current institution, year hired by current institution, year appointed FL, and the Scopus H-index. Additional statistical analyses, including Pearson correlation coefficients, were determined via Statistical Packaging for Social Sciences (SPSS) version 24 (IBM Corporation, Armonk, NY). Software. Data were interpreted according to Mukaka guide for correlation coefficients.18


Information was completed for 103 fellowship leaders composed of 67 sole fellowship directors, 19 co-FDs, and six individuals with a synonymous leadership title (Table 1). Of the total 103 FLs, 99 (96.1%) of the leadership consisted of males while four (3.9%) were female. The calculated mean age was 52.9 years old, and the mean Scopus H-index was 23.8. Included FLs completed residency programs in orthopedic surgery (n = 89, 86.4%), neurosurgery (n = 13, 12.6%), or combined orthopedic surgery and neurosurgery training (n = 1, 0.971%) (Table 2). The mean calendar years for completion the residency and fellowship training were 1999 and 2001, respectively.

The Roles, Demographics, and Training of Spine Fellowship Leaders
Education, Employment, and Leadership Progression of Spine Fellowship Leaders

Among our results, we report the 10 most impactful FL in research based on the Scopus H-index (Table 3). Specifically, the two most impactful FLs in research equaled their Scopus H-index values at 91. The tenth most impactful FL in research had a Scopus H-index value of 47 (accessed April 25th, 2019).

Research Impact of Spine Fellowship Leaders as Determined by Scopus H-Index

The top four residency programs that produced future FLs were Case Western Reserve University, Cleveland (n = 7), University of California, San Diego (n = 4), Johns Hopkins University, Baltimore (n = 4), and Hospital for Special Surgery, New York (n = 4). Residency programs at which at least four FLs trained were included (Figure 1).

Figure 1
Figure 1:
A summary of the most attended residency training programs among current spine fellowship leaders. Note: Residency programs at which at least four fellowship leaders trained were included. FL indicates fellowship leader.

The top three fellowship programs that produced future FLs were Case Western Reserve University, Cleveland (n = 10), Washington University, St. Louis (n = 9), and Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia (n = 7). Fellowship programs at which at least six FLs trained were included (Figure 2).

Figure 2
Figure 2:
A summary of the most attended fellowship training programs among current spine fellowship leaders. Note: Fellowship programs at which at least six fellowship leaders trained were included. FL indicates fellowship leader.

Six FLs served as President of SRS, four FLs served as President of CSRS, and three FLs served as President of NASS (Figure 3). The Scopus H-indices for FLs were separated in ranges that included 1 to 15 (n = 39), 15 to 29 (n = 31), 29 to 43 (n = 17), 43 to 57 (n = 9), 57 to 71 (n = 4), 71 to 85 (n = 1), and 85 to 99 (n = 2) (Figure 4).

Figure 3
Figure 3:
A description of the number of fellowship leaders serving as presidents of the three major Spine Societies for at least a 1-year term during the period of 2003 to 2019. Note: FL indicates fellowship leader.
Figure 4
Figure 4:
A representation of the Scopus H-indices of all spine fellowship leaders. Note: The Scopus H-index values are as of April 25, 2019. Interval notation is used. “(Indicates that the range includes the adjacent numerical value.)” “(Indicates that the range does not include the adjacent numerical value).” FL indicates fellowship leader.


Perhaps the most remarkable observation was the level of research prowess within the leadership group. The mean Scopus H-index for fellowship leaders in this study was 23.75, while most fellowship leaders maintain Scopus H-indices above 15 and reached Scopus H-indices as high as 91. These findings elucidate a propensity for spine fellowship programs to select leaders with a strong research background, though also the immense impact that fellowship leaders on the field through devotion of time academic pursuits. Previously, in a study by Schoenfeld et al,19 the academic productivity and literature contributions of spine surgery fellowship faculty were identified. Schoenfeld et al19 considered all physicians listed as faculty at a spine fellowship program in the directory of the NASS and measured the Scopus H-indices at various timeframes. Of note, among the study's cohort, there was a reported mean Scopus H-index of 13.6. Although this average was established based on all listed faculty members on the NASS directory in 2014, there is still a noted difference from the mean of 23.75 we identified among fellowship leaders.

Another interesting observation was the potential correlation between specific training programs and production of future fellowship leaders. The most attended fellowship programs among current spine FLs include Case Western Reserve University (n = 10), Washington University (n = 9), and the Rothman Institute at Thomas Jefferson University (n = 7). Although it is not objectively clear why attending these specific programs could result in appointment to spine fellowship director, there are some possible explanations. Perhaps these programs are inclined to offer training positions to individuals with a desire to seek academic leadership positions demonstrated by past leadership roles. Additionally, these programs may have training curriculums in place that establish skills suitable for attaining leadership roles. The influence of professional networks and reputation should not be overlooked, as having completed a particular training program may offer unique opportunities to fill faculty positions at a given institution. Regardless of causal factors, there appears to be a hierarchy among training programs when analyzing alumni in eventual career developments.

Interestingly, there was a small percentage of female representation (4%) in spine leadership at the fellowship level. This finding is likely a result of the fact that historically orthopedic surgery, and particularly spine surgery, has been a male dominated field. While residency programs are graduating females at a higher rate than in the past, it will likely take many years for this discrepancy to be reflected at the leadership level due to the required matriculation and experience level that must first occur prior to such FL appointments.

This study did have some limitations in that our group relied on obtaining CVs in order to establish and develop our data sets. In doing so, some CVs could not be obtained, while others could be out of date. An additional factor is that CVs are typically self-reported and can contain errors. In that communication with spine fellowship programs were made with the administrative staff and the contact number on the NASS directory was used, at times, contact with FLs was not universally achievable.

Lastly, as a cross-sectional study this research established demographic trends of spine fellowship director at one point in time. Results could vary if a year-by-year comparison was executed. An additional inherent limitation lies in the objective nature of data collected and analyzed. This work does not speak to the many subjective factors that influence each individual's career path, from professional mentors and the desire to teach new surgeons to personal factors affecting career trajectory.

Frequently, spine surgeons who fulfill and maintain fellowship program leadership roles are characterized by a track record of research productivity. Additionally, spine surgery fellowship directors are more likely to have graduated from certain residency and fellowship programs. This could be due to the training provided by these centers or the institution's predilection to select applicants that are more likely to seek academic leadership roles post-graduation. Potentially one aspect of developing leadership skills could be the interaction with the host program's orthopedic residents. Through consultation management and daily interactions with the orthopedic residents, those spine surgery fellowships with a residency component might have a unique advantage of fostering a leadership and teaching role for their spine fellows. This creates a repetitious environment where program directors tend to select from a familiar pool of applicants, and ultimately fellowship directorships end up being replaced by individuals with similar distinctions as them.

Key Points

  • Spine surgery fellowship leaders are more likely to have trained at certain residency and fellowship programs.
  • Demographic trends may play a role in deciding the future spine leaders in America, and, thus, should be better understood.
  • We highlight the institutions that may provide a framework of leadership in the field of spine surgery.


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medical education; orthopedic fellowship; orthopedic leadership; orthopedic surgery; spine fellowship; spine surgery

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