Candidates who are eligible for the Part-II oral examination of the
American Board of Orthopaedic Surgery (ABOS) may select their specific
subspecialty area for testing after fellowship training. Subspecialties are
hand, spine, pediatrics, sports, adult reconstruction, trauma, oncology, and
foot and ankle. Subspecialization means that the candidate commits at least
50% of his or her practice to that subspecialty. This would be declared and
reflected in the list of cases managed during the collection period, defined
as six consecutive months of operative cases, beginning July 1 of the year
prior to the Part-II examination. Sixty-five to seventy orthopaedic surgeons
who are part of the oral examination group review the case lists submitted by
the applicant and select twelve cases for the oral examination of which two
cases can be deleted by the candidate. For each case selected, the candidate
must provide the following: (1) notes from the initial history and physical
examination (the first visit), (2) notes on the operative procedure, (3) notes
from an office visit made at a minimum of three months postoperatively, (4)
the discharge summary as well as information on all relevant consultations
obtained concerning the care of the patient, and (5) all relevant imaging
studies made preoperatively, intraoperatively, and postoperatively. All
records must be organized to allow examiners ready access to these
materials.
In addition to the specialty case list, a candidate who selects a
subspecialty designation will be examined by three sets of examiners with two
examiners in each group. The ABOS guarantees candidates that at least one
examiner in each examination group will be a subspecialist in that designated
area. This ensures a fair and knowledgeable exchange of information between
the candidate and the examiner and ensures that the interactions will reflect
the most up-to-date evidence-based information in that subspecialty.
What is expected from the candidate by the examiners to successfully pass
Part II of the examination? The ABOS has provided residency program directors
and candidates with the rating scales used by examiners in evaluating the case
lists and presentations (see Appendix). In essence, the candidate is judged
both on the cases themselves and on the six skills with defined rating scales.
This means that record-keeping, case mix, and complications are carefully
evaluated to arrive at the case list score. The presentation of cases must
include the candidate's decision-making processes, indications, treatments
(operative and nonoperative), a defense of his or her patient care based on
the published literature, and, finally, the ability to discuss complications
and adverse outcomes in a rational manner.
It is logical to assume that residency and fellowship training along with
early practice experience factor heavily into the candidates' ability to
complete the Part-II examination successfully. Although this discussion
applies to all of the subspecialty areas, the remaining comments are directed
to those surgeons who have designated spine as their
subspecialty.
The foundation of a comprehensive spine education begins in one's residency
program. During that period, an orthopaedic resident should gain the core
knowledge related to the basic science of various spinal maladies; develop the
ability to formulate differential diagnoses and manage common spinal problems
in an office setting; and learn the indications, risks, benefits, results,
outcomes, and complications of spinal disorders, including herniated and
degenerative discs, spinal stenosis, sciatica, arthritis, deformity, tumor,
infection, and trauma.
Residency Education
The core spine knowledge expected of a resident completing an orthopaedic
residency program is listed in the
Appendix1.
A solid foundation laid during residency training prepares a resident to be
successful as a spine fellow. Building on the knowledge and experience gained
during residency, the fellow is able to gain further insight into the
pathophysiology of the multiple abnormalities that affect the spinal column as
well as the indications for surgical treatment.
Fellowship Education
The fellowship year is the time to acquire decision-making skills and to
become thoroughly familiar with surgical techniques, which hopefully will be
mastered in practice. That year should teach surgical indications, alternative
nonoperative therapies, outcomes, and associated complications.
The educational and procedural elements in which an orthopaedic spine
surgery fellow should be competent on successful completion of the fellowship
training program are presented in the
Appendix2.
It is recognized that programs have varied emphases such as degenerative
disease, deformity, or trauma. No program will provide the full breadth of
experience in all procedures. However, it is expected that an orthopaedic
spine fellow should have mastered basic spinal surgery knowledge and surgical
skills on completion of the program. Understanding how complications occur and
how to manage them effectively separates an average surgeon from an excellent
surgeon. The fellow must also learn expected results and outcomes and develop
the confidence necessary to speak with patients and their families to provide
them with an evidence-based informed choice (traditional informed
consent)3.
Ethics and professionalism are rooted before residency begins but are
fine-tuned during residency and fellowship training. How the fellow
(soon-to-be practitioner) interacts with industry should also be taught during
the fellowship
year4.
In order to become a complete spine surgeon, the resident and, later,
fellow must have the proper mentors who understand the educational
process.
Spine fellowships offer a wide spectrum of training from those that focus
on low-back pain to those that focus on deformity-based disease. Regardless of
the fellowship focus, there are standards of education and training that
should apply to each program and that are used in the fellowship accreditation
process of the Accreditation Council for Graduate Medical Education (ACGME).
There must be a commitment in training programs to education rather than to
service. Research experience is also essential to help the fellow to develop
the ability to critically evaluate practice patterns, surgical procedures, and
the literature. Having regular conferences, journal clubs, and mortality and
morbidity conferences provides the academic feedback necessary to improve
one's performance and, therefore, to improve patient care. Fellowship programs
that are accredited by the ACGME Residency Review Committee ensure that these
principles of education and training are present. They ensure that the
fellowship institutions provide the necessary resources that are necessary to
support the fellows' education and training such as classrooms, libraries,
research facilities, and educational materials. This information is outlined
in detail in the Graduate Medical Education Directory (the Green
Book)5.
Some fellowships, however, may be more service oriented than education
oriented. This defeats the educational goals of the fellowship program and
places the fellow candidate for the Part-II examination at a significant
disadvantage. Without the necessary educational feedback and interaction, the
candidate presenting his or her cases before the spine examiners may not be
able to adequately explain the indications for a procedure, why he or she
achieved a less than optimal result, or why an inordinate number of
complications occurred. It is the responsibility of every potential fellowship
candidate to make certain that the fellowship program that he or she selects
fulfills the educational requirements to provide the training necessary to
help to ensure the successful completion of the Part-II examination.
Table I presents the results
on the Part-II examination for 2002 through 2005 for the spine candidates and
compares them with the overall pass-fail rates for all candidates who took the
examination.
The number of failures raises concerns for those electing to engage in
spine fellowships. Are the fellows receiving sufficient education and
procedural feedback to perform satisfactorily on the Part-II examination?
Fellowship accreditation through the ACGME with a specific curriculum and
educational goals may help to ensure the necessary resources for the fellow to
be successful on the Part-II oral examination.
Program and Accreditation
In a review of orthopaedic spine fellowship programs whose graduates
completed the Part-II oral examination from 2002 to 2005, it was noted that
eight programs had more than one candidate fail during the three-year review
period. Of these eight programs, only one had accreditation through the ACGME.
The review included forty-seven orthopaedic spine fellowship programs in the
United States. Of the twelve accredited spine fellowships, only one program
had more than one fellow who failed (8%), while fellows from nonaccredited
programs failed at nearly three times the rate of those from accredited
programs (20%).
It is not the function of the ABOS to mandate fellowship accreditation, but
it is the function of the ABOS to test and to certify the candidates who
successfully complete the examinations. Fellowship accreditation in
orthopaedics is granted by the Residency Review Committee in Orthopaedic
Surgery, as an extension of the ACGME, on completion and review of the
application initiated by the specific program seeking accreditation.
Fellowship accreditation is treated in a similar manner to residency
accreditation. It requires periodic site visit reviews by the Residency Review
Committee, which submits a written program summary.
As has been stated, accreditation cannot be mandated, but the data strongly
suggest that the programs with accreditation emphasizing education, and not
just service, provide a fellow candidate a better chance of being successful
on the Part-II examination.
Nonaccredited Programs
It should also be stated that nonaccredited programs can provide an
educational framework along with facilities and resources that are similar to
those of accredited programs. These programs do not, however, undergo periodic
review; therefore, there is no assurance that such programs provide a similar
educational environment. It is up to each fellowship applicant to inquire of
prospective programs as to what educational clinical and research resources
are available. It is also the fellowship applicant's responsibility to inquire
as to the pass-fail rate of prior fellows who graduated from that specific
program, before making a decision on which program to attend.
Subspecialty Certification
One may ask whether the natural progression of this process is to require
accreditation of all fellowships and, ultimately, to require subspecialty
certification for orthopaedic spine surgery. Is spine surgery headed down the
same path as hand surgery, which created subspecialty certification, the first
Certificate of Added Qualification, in 1989? This may be best for our fellows
and the public we serve. The main purpose of subspecialty certification is to
establish a fund of knowledge within the field and, ultimately, to improve the
quality of medicine being practiced within the subspecialty.
In an article in the American volume of The Journal of Hand
Surgery in 1982, Smith elucidated five crucial elements in the
consideration of subspecialty certification in hand
surgery6.
The prevalence of upper extremity disorders.Subspecialty certification could cause fragmentation of the parent boards
(orthopaedic, plastic, and general surgery).Hand surgery is a distinct body of knowledge.Exclusivity and/or better care.De facto certification already existed.
The prevalence of upper extremity disorders.
Subspecialty certification could cause fragmentation of the parent boards
(orthopaedic, plastic, and general surgery).
Hand surgery is a distinct body of knowledge.
Exclusivity and/or better care.
De facto certification already existed.
Without going into detail on each point, the field of spine surgery
contains elements similar to those of hand surgery. The granting of the
subspecialty certificate in hand surgery led to a mandating of fellowship
accreditation before a candidate could sit for the hand surgery certification
examination. In addition, the candidate had to perform 125 hand procedures per
year and devote 75% of his or her practice to hand surgery.
There have been attempts by different organizations to pursue spinal
certification. The Scoliosis Research Society submitted an application to the
ABOS several years ago for a subspecialty certification in spinal deformity;
however, the Society has not continued to pursue this goal at the present
time.
The exigency at this time is to see that our candidates for the Part-II
examination receive the appropriate education and have the necessary resources
to prepare them to be successful on the examination. More importantly, it is
our public duty and responsibility to train the best clinicians in their area
of subspecialty interest. In times of limited resources and
pay-for-performance initiatives by the federal government, we cannot afford to
train fellows in any area without specific measurable educational goals and
objectives.
The grading system used for the American Board of Orthopaedic Surgery
Part-II oral examination, the core knowledge requirements in spine for
orthopaedic residents, and the educational guidelines for fellowship training
in spine surgery are available with the electronic versions of this article,
on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM).