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Spine surgery training: is it time to consider categorical spine surgery residency?
The Spine Journal 15 (2015) 1513–1518
Perspective
Spine surgery training: is it time to consider categorical spine surgery residency? Alan H. Daniels, MDa,*, Christopher P. Ames, MDb, Steven R. Garfin, MDc, Christopher I. Shaffrey, MDd, K. Daniel Riew, MDe, Justin S. Smith, MD, PhDd, Paul A. Anderson, MDf, Robert A. Hart, MDg a Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley Street. Providence, RI 02905, USA Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave., Rm. M779, San Francisco, CA 94143, USA c Department of Orthopaedic Surgery, University of California San Diego, Perlman Ambulatory Care Center, 9350 Campus Point Drive, La Jolla, CA 92037, USA d Department of Neurological Surgery, University of Virginia, P.O. Box 800386, Charlottesville, VA, 22908, USA e Department of Orthopaedic Surgery, Washington University, Cervical Spine Institute. 4921 Parkview Place, A12, St. Louis, MO 63110, USA f Department of Orthopaedic Surgery, University of Wisconsin, 1685 Highland Ave., UWMFCB – 6215, Madison, WI 53705, USA g Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA b
Received 30 July 2014; accepted 17 August 2014
FDA device/drug status: Not applicable. Author disclosures: AHD: Trips/Travel: Stryker Spine (B, Paid directly to institution), DePuy/Synthes (A, Paid directly to institution). CPA: Royalties: Aesculap (C), Biomet Spine (E); Stock Ownership: Doctors Research Group (100 shares), Baxano Surgical (1,000 shares), Visualase (2,000 shares); Consulting: Medtronic (B), Stryker (B), DePuy (C). SRG: Royalties: DePuy Spine (I); Stock Ownership: Cross Tree (25,000 Shares), Interventional Spine (20,000 shares), Pioneer Surgical (10,000 shares, Consultant/speaker honoraria), Spinal Kinetics (10,000 shares), Spine Medica (25,000 shares), Surgifile (50,000 Shares), Cytonics Corporation (2,500 Shares), SI Bone, Inc. (200,000 shares); Consulting: Applied Spine Technology (B, Paid directly to institution/ employer), Magnifi Group (B, Paid directly to institution/employer), Cytonics (None), SI Bone, Inc. (A), Globus Medical (A), Benvenue Medical (C), NuVasive (D, Paid directly to institution/employer), Spinal Kinetics (None); Speaking/Teaching Arrangements: DePuy (Financial, reimbursement for travel and time), Biomet (Financial, reimbursement for travel and time); Board of Directors: Spine Arthroplasty Society (Financial, hotel reimbursement); Scientific Advisory Board: NuVasive (C, Paid directly to institution/employer), Spinal Kinetics (None), Spine Medica (None), Vertiflex (None), SI Bone, Inc. (None), Benvenue Medical, Inc. (B); Research Support - Staff/Materials: DePuy, Inc. (D, Paid directly to institution/employer), EBI (D, Paid directly to institution/employer), Medtronics (E, Paid directly to institution/employer), NuVasive (E, Paid directly to institution/employer); Fellowship Support: Synthes Spine (E), DePuy (E), Medtronics (E), Biomet (D). CIS: Royalties: Medtronic (F, Paid directly to institution), Biomet (D, Paid directly to institution); Consulting: Biomet (C), Globus (C), Medtronic (D), Nuvasive (C), Stryker (B); Grants: National Institutes of Health (D, Paid directly to institution), Department of Defense (F, Paid directly to institution), AO (E, Paid directly to institution), Neurosurgery Research and Education Foundation (E, Paid directly to institution), NACTN (F, Paid directly to institution); Fellowship Support: NREF (E, Paid directly to institution), AO (E, Paid directly to institution), University of Virginia (E, Paid directly to institution). KDR: Royalties: Biomet, Medtronic (G); Stock Ownership: Amedica; Benvenue; Expanding Orthopedics; Nexgen Spine; Spinal Kinetics; Spineology; Vertiflex; PSD (F); Speaking and/or Teaching Arrangements: AOSpine; New England; Royalties: Biomet (F), Osprey (C), Medtronic (G); Stock Ownership: Amedica (B), Benvenue http://dx.doi.org/10.1016/j.spinee.2014.08.452 1529-9430/Ó 2015 Elsevier Inc. All rights reserved.
(C), Expanding Orthopedics (B), Nexgen spine (B), Osprey (C), Paradigm Spine (B), Spinal Kinetics (C), Spineology (B), Vertiflex (B), PSD (B); Speaking and/or Teaching Arrangements: AOSpine (Honorarium), NASS (Honorarium); Trips/Travel: AOSpine (reimbursement only), NASS (reimbursement only), SRS (reimbursement only), Broadwater (reimbursement only), Selby Spine (reimbursement only); Board of Directors: CSRS (Past-President, 2012-2013, unpaid position), Global Spine Journal (Deputy Editor, unpaid position), AOSpine (Chair-elect & Research Chair, International Board, paid position), NASS (unpaid position); Grants: AOSpine (B, Paid directly to institution), Cerapedics (A, Paid directly to institution), Medtronic (C, Paid directly to institution for FDA-IDE study); Fellowship Support: AOSpine (Paid directly to institution). JSS: Consulting: Biomet (D), Cerapedics (B), Nuvasive (0), Medtronic (B); Speaking and/or Teaching Arrangements: Biomet (D), Globus (C), DePuy (C), Nuvasive (C); Grants: DePuy/ISSGF (D, Paid directly to institution); Fellowship Support: NREF (E, Paid directly to institution), AO (E, Paid directly to institution). PAA: Royalties: Styrker (D); Stock Ownership: SI Bone (!1%), Pioneer surgical (!1%), Titan Surgical (!1%), Expanding orthopedics (!1%), Spactec (!1%); Consulting: Stryker (E), Pioneer surgical (B), Aescualp (C). RAH: Grant: International Spine Study Group Foundation (C, Current/Active Grants), Medtronic (F); Royalties: SeaSpine (E), DePuy (B); Stock Ownership: SpineConnect (C); Honoraria: DePuy (C); Consultancy: DePuy (C), Globus (B), Medtronic (C); Speaking and/or Teaching Arrangements: DePuy (C); Board of Directors: CSRC Board, ISSLS, ISSG Executive Committee; Patent: US-2010-0268230-A1: Method and Apparatus for Dens Fracture Fixation (Pending, no sales to date). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. No funding was obtained for this study. No funding was obtained in support of this work. The authors have no relevant financial conflicts of interest to disclose related to this work. * Corresponding author. Department of Orthopaedics, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA. Tel.: (401) 444-4030; fax: (401) 444-6182. E-mail address: [email protected] (A.H. Daniels)
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Introduction Spine surgeon training in the United States consists of either an orthopedic or a neurological surgery residency program followed by an optional spine surgery fellowship [1,2]. Currently, orthopedic spine surgeons receive limited exposure to spine surgery during residency, then the vast majority go on to complete a spine fellowship before beginning independent spine surgery practice [3–6]. Most neurological surgeons receive exposure to spine surgery throughout residency, and some may even focus their final year of residency training on spinal conditions but do not necessarily complete a spine fellowship before performing spine surgery in practice [3,7]. Despite published guidelines for spine surgeon training regardless of specialty [8], the two separate training models provide trainees with different spine surgery exposure in terms of case load and case variety [3,5,9,10] and result in different experience levels and decision-making skills in treating spinal disorders at the conclusion of residency training [11–14]. The specialty of spine surgery has expanded to become a much more vast and complex discipline in recent years. Ideally, spine surgeons would be expected to master nonoperative spinal care in addition to many surgical techniques before independent practice, now including minimal access surgery, anterior and posterior spinal instrumentation, deformity of both cervical and thoracolumbar spines, motion-preserving approaches, and a host of interbody fusion techniques. Although both specialties bring unique perspectives to the art and science of spine surgery, the current two distinct specialty pathway training models may not be the optimal environment for educating tomorrow’s spine surgeons as wide variations in training may be detrimental to surgeon quality and patient care. Orthopedic spine surgery and neurological surgery each have rich histories and strong traditions in caring for spinal disease and innovative treatments. However, neither discipline offers a spine surgical training pathway intentionally designed to provide optimal experience from the standpoint of the current spine surgical environment [3]. In the future, spine surgery may benefit by having its own residency training in an effort to improve spine surgeon training and improve the quality of spine care provided in the United States.
The current state of spine surgery Major surgical advancements in spine surgery have come from both orthopedic and neurological surgery disciplines [15]. In the last 30 years, new ways to approach, instrument, arthrodese, and correct deformity of the spine have been successfully developed. These innovations stemming from the two specialties have helped form a collaborative bond between the specialists, yet the relationship between the two has also been and continues to be adversarial at times [15]. This truth must be acknowledged by all if positive change is hoped for.
With partnering in the development of modern spinal surgery, the art and science of spine surgery have advanced. Some spine surgeons now subspecialize in minimally invasive spine surgery, cervical spine surgery, spinal tumor surgery, motion-preserving spine surgery, pediatric spine surgery, and spinal deformity surgery. Although the principles of spine surgery may be mastered by individuals, it is increasingly unlikely that an individual spine surgeon can master all aspects of spinal surgery. Learning the practice of spine surgery through the traditional orthopedic and neurological surgery pathways is becoming increasingly difficult, as duty hour and supervisory restrictions have been implemented, while the breadth of surgical techniques continues to expand rapidly. A second important acknowledgment is the recognition that neither of the current pathways was designed with the modern spine surgical practice in mind, and neither provides an optimal approach to mastery of that environment and skill set (operative and nonoperative) [3]. Unfortunately, spine surgeons have recently been criticized for performing too much spine surgery, and for performing poor quality spine surgery, both in the lay press and the scientific literature [16–19]. The reputation of spine surgery has been tarnished and will require improved care by spinal surgeons if it is to be repaired. An important first step is recognizing the need, and therefore the opportunity, to improve our training programs with the intent of improving practice patterns and patient care. An additional concern is the 28% failure rate on Step II of the American Board of Orthopedic Surgery for orthopedic spine surgeons, the highest of any orthopedic specialty [20]. This may be, in part, because of suboptimal training regarding spinal pathology during both residency and fellowship. Spine training: is the current model optimal? Is it optimal to have two separate paths in spine surgery training? It is possible that 1 year of spine training after an orthopedic surgery residency program is insufficient to master the operative and decision-making skills necessary to independently practice spine surgery for many trainees. Trainees at orthopedic surgery programs with highvolume spine divisions, who are interested in spine surgery early in residency training, may receive adequate exposure and education in spine surgery to be proficient at spine surgery after a 1-year fellowship. However, trainees at programs with low-volume spine divisions, or who have decided to pursue spine training late in residency, may be poorly prepared for spine fellowship and may still be ill prepared for independent spine practice after a 1-year fellowship. Additionally, there is a lack of standardization for spine surgery fellowships [21], thus providing further variation in the training process. Separately, is a 7-year residency program sufficient to gain surgical knowledge and independence in all aspects of neurological and spinal surgery? Neurological surgery
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residency prepares trainees to perform basic spine surgery, but spinal deformity surgery and complex spinal reconstruction likely require additional dedicated fellowship training [3], thus resulting in 8 or more years of postgraduate medical training. Is this a reasonable expectation for the next generation of spine surgeons? In the current model of spinal surgery training, neurological surgery residency typically provides a strong background in neurotrauma, intradural processes, cerebrospinal fluid management, central nervous system tumors, and minimally invasive approaches, whereas orthopedic surgery training may not provide adequate exposure to these topics (Table 1). In contrast, orthopedic surgery residency typically provides a strong background in bone physiology, bone and soft tissue healing, skeletal growth and development, biomechanics, peripheral joint arthrosis, material science of implants, and scoliosis, whereas neurological surgery may not provide adequate exposure to these topics. These differences in educational pathways may result in different approaches to spine care [11–14]. There are also inconsistencies in training both between and within each specialty in terms of nonoperative care of spinal pathology, and in education regarding the natural history, outcomes, and timing of surgical interventions. These differences in educational pathways result in differences in spine surgery practices [3,5]. It is reasonable to suggest that the ability to provide balanced exposure to all these topics during training would be better. In addition to different educational focuses between the specialties, the Accreditation Council for Graduate Medical Education (ACGME) case log data reveal a large amount of variation both within and between the specialties in terms of spine surgery case exposure [5]. For example, orthopedic surgery graduates average 160 spine surgery procedures completed during residency, whereas neurological surgery residents average 375 spine surgery procedures [5]. Additionally, there is substantial variability in spine surgery exposure within each specialty, with the greatest variability seen in instrumented procedures. For spinal instrumentation/arthrodesis procedures, there is a 13-fold difference between the top and bottom 10% of orthopedic surgery residents and an eightfold difference between the top and bottom 10% of neurosurgery residents [5]. Furthermore, differences exist between orthopedics and neurosurgery in terms of ACGME spine surgery minimum Table 1 Strengths in training for each specialty Orthopedic surgery
Neurological surgery
Bone physiology; bone and soft tissue healing Skeletal growth and development Biomechanics Peripheral joint arthrosis Material science of implants Scoliosis
Neurotrauma Intradural processes Cerebrospinal fluid management Central nervous system tumors Minimally invasive approaches Spine surgery exposure throughout residency
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case requirements. These minimums are strikingly different between the two specialties and are at levels that are likely far below the minimum needed to achieve proficiency. The ACGME has determined that orthopedic surgery residents should perform no fewer than 15 ‘‘spine decompression/posterior spine fusion thoracic or lumbar’’ procedures during residency. In contrast, neurological surgery residents are required to perform no fewer than 85 adult spinal procedures, five cervical spine traction procedures, and five pediatric spine procedures during residency [22,23]. Spine surgery residency We believe that a focused and structured spine surgery training pathway could improve the quality of spine training and thus improve the care of spine patients treated in the United States. There are robust data supporting the fact that subspecialty surgeons who perform high volumes of a specific procedure have improved outcomes over surgeons who perform lower volumes of the same procedure [24– 26]. Additionally, residents with greater exposure to complex surgical procedures tend to have lower complication rates [27]. Although we are not aware of data specific to spine surgery, it is logical to assume that spine specialty–focused providers have improved outcomes over spine providers who do fewer spine procedures or include spine surgery within a more broadly focused practice. Spine surgery residency would foster a spine-centric education, with the ultimate goal of a spine-specific practice, with an expected effect of improving patient outcomes. An optimal spine surgery training program would be efficient in its aim to train spinal surgeons, focused on useful skills and knowledge for surgeons who will dedicate their practice solely to spine surgery. The exposure would ideally provide adequate breadth of operative and nonoperative experience to trainees, while ensuring competency before the completion of training. If spine surgeons wish to develop their own categorical residency training, it is important to explore the experiences of other surgical specialties that have successfully split from their parent specialty to form their own residency training programs, such as vascular surgery. Vascular surgery training required completion of a general surgery residency, followed by a vascular surgery fellowship up until the year 2006. Vascular surgeons began the movement for separation from general surgery and for board certification in the 1970s with an investigation by a committee from the American Board of Surgery (ABS) [28]. In 1981, the ABS won approval from the American Board of Medical Specialties (ABMS) to offer a certificate in vascular surgery. Over 30 years later, in 2006, vascular surgery became a primary specialty of the ABS, and certification in general surgery was no longer a prerequisite for certification in vascular surgery. This created the option of vascular surgery residency training.
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Today, 5-, 6-, and 7-year training options exist to obtain vascular surgery training. These options include 5 years of dedicated vascular surgery residency training, 5 years of general surgery training with a 2-year vascular fellowship, in addition to a combination of 3 to 3 and 4 to 2 year options available as well [29]. These options allow trainees to choose whether they wish to be board certified in both general surgery and vascular surgery or just in vascular surgery. A similar model could be adopted in spine surgery, with a variety of training options, including a shortened primary orthopedic or neurological surgery residency, followed by a prolonged spine surgery fellowship. Trainees would still be able to pursue spine surgery fellowship after traditional ‘‘complete’’ orthopedic or neurological surgery residencies. This would allow spine surgeons who trained through the traditional paths to practice general orthopedics or neurosurgery, in addition to spine surgery, and to obtain board certification in their specialty. Trainees who complete spine surgery residency would be dedicated spinal surgeons, without sufficient training to perform general orthopedic or neurological surgery. A desirable institution for a spine surgery residency would have a wide breadth of spine surgery with exposure to basic spine surgery, minimally invasive, deformity, tumor, and traumatic spine conditions. Ideally, development would occur as a collaborative effort between the orthopedic surgery and neurological surgery spine divisions to promote a well-rounded educational experience.
In the future, there may be independent Departments of Spine Surgery that would facilitate an independent training program. Additionally, a Department of Spine Surgery could have a nonoperative division, focusing on the nonsurgical aspects of spine care, which would act to supplement spine surgeon resident training. This model already exists in many academic orthopedics departments, where divisions of Sports Medicine have fellowship-trained physicians in both primary care and orthopedic surgery. A spine surgery residency program would be designed to provide pertinent rotations to optimally train spine surgeons. This may vary from institution to institution based on local resources, although ACGME requirements would have to be developed. One proposal of how a spine residency rotation schedule might be structured is offered here to help drive the discussion (Table 2). In all rotations, a combination of outpatient and inpatient care would be available. When spine surgery residency is implemented, ongoing evaluation will be needed to examine its effectiveness at training tomorrow’s spine surgeons. Challenges of implementation: process of implementation The development of spine surgery residency will face numerous challenges and barriers. The political challenges associated with the development of a dedicated spine surgery training pathway are
Table 2 Proposed residency training schedule with knowledge goals for each rotation PGY1 General surgery TICU/SICU Physical medicine and rehabilitation Medicine Emergency room Anesthesia Thoracic surgery Otolaryngology Radiology PGY2 Orthopedic: trauma Orthopedic arthritis/arthroplasty Neuroradiology: interventional radiology Neurological surgery: trauma Neurological surgery: tumor Neurological surgery: intracranial, interventional Neurological surgery: ICU PGY3 Spine surgery: trauma Spine surgery: elective spine PGY4 Spine surgery senior resident PGY5 Spine surgery chief resident PGY6 (optional fellowship year through match) Advanced spine fellowship: deformity, MIS, tumor, pediatric spine, arthroplasty, etc
Knowledge gained/goals for rotation Fluid management, surgical principles Critical care Nonoperative spine care, rehabilitation principles Medical care Spine trauma, critical care, airway management Spinal anesthesia, airway management Thoracic approaches, chest tube management Cervical approaches, airway management Imaging, interventional spine techniques Extremity trauma, fracturecare Degenerative orthopedic disorders, tribology Advanced imaging, percutaneous techniques Neurotrauma Neuro-oncology Neurodegenerative disorders Neuro critical care Spinal trauma: operative and nonoperative Degenerative spinal conditions, deformity Surgical autonomy increased Increased responsibility appropriate to level of ability, transition to independent practice Advanced/subspecialized spine techniques
PGY, post graduate year; TICU, trauma intensive care unit; SICU, surgical intensive care unit; MIS, minimally invasive surgery.
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substantial. The structure of orthopedic and neurological surgery departments at many institutions may not easily accept a change in the status quo regarding their spine division and trainees. Additionally, spine surgeons’ assertion that the current training system was ‘‘good enough for me’’ may provide additional argument against a major change in current spine surgeon training, although it must be recognized that today’s training environment and training demands are not equivalent to those of yesterday. Potential economic barriers to spine residency training also exist. Training programs are financially costly to departments, and financial hurdles may provide additional challenges in spine surgeon training reform. Concerns regarding the loss of spine surgery revenues for departments will arise, and removing spine surgery revenue from orthopedic and neurological surgery departments may initially be perceived as detrimental. However, with the advent of spine surgery residency, spine divisions could still be part of both orthopedic and neurological surgery departments, with revenue shared between them. This would allow the hiring of the best spine surgeon candidates, regardless of training background. Even if departments support the development of spine residency, additional barriers from the ACGME may arise. A formal petition to the ACGME Board is needed to develop new specialties recognized by the ACGME, which will provide the opportunity to present the argument that spine training could be improved with dedicated spine surgery resident training. If the ACGME approves a spine surgery residency training pathway, accreditation standards would need to be developed. This would necessitate discussion and development of minimum standards during spine surgeon training, beyond the current standards set for orthopedic and neurological surgery. There is also concern that spine residency development may set a precedent for further subspecialization within the orthopedic and neurological surgery professions, which could decrease the available pool for general orthopedic and neurological surgery emergency call physicians. Although these concerns are valid, they certainly should not serve as a primary reason to prevent change in training, which will lead to substantial improvements in spine patient care. An important additional consideration is that board certification in orthopedic surgery and neurological surgery will not be available to spine surgery resident trainees. Thus, a universally accepted Board for Spine Surgery will be necessary for ensuring adequate training, knowledge, and commitment to lifelong learning. The American Board of Orthopedic Surgery or the American Board of Neurological Surgery may wish to develop the dedicated Spine Surgery Board Certification. According to the ABMS, there are several key criteria for creating new medical examining boards, all of which would need to be fulfilled by spine surgery if a dedicated board is to be created [30]:
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1. The differentiation of a new specialty must be based on major new concepts in medical science and represent a distinct and well-defined field of medical practice. 2. A single standard of preparation for, and evaluation of, expertise in each specialty must be recognized by only one medical specialty board for each specialty. 3. The training needed to meet certification requirements by the applicant must be distinct from that required for certification by approved ABMS Member Boards so that it is not included in established training programs leading to certification by approved ABMS Boards. 4. A medical specialty board must demonstrate that candidates for certification will acquire, and its’ diplomates will maintain capability in a defined area of medicine and demonstrate special knowledge and competencies in that field. 5. Evidence must be presented that the new board will establish defined standards for training and that there is a system for evaluation of educational program quality. 6. The applicant medical specialty board must demonstrate support from the relevant field of medical practice and broad professional support. Discussion The current model of training has provided society with a group of highly skilled spinal surgeons. However, the world is changing around us, and the old model of training is no longer the most efficient and effective strategy for training tomorrow’s spine surgeons. Change in medicine can be a challenging process. However, we should consider that progress in our field must be pursued for the benefit of both patients and trainees. There is a need for a deliberately designed, efficient, spine surgery training pathway to improve spine surgeon training and thus spine patient care. Numerous major changes to medical practice and training, such as acceleration in pay for performance strategies, medical informatics, quality initiatives, competency-based learning, virtual classrooms, and haptic motor simulation strategies, are being implemented. Surely, these initiatives should carry over into efforts to optimize training programs, even if initially disruptive to current practitioners and teachers. To move this discussion forward, an exploratory committee should be developed to examine the issue of spine surgeon training reform. Members of this committee should come from both orthopedic and neurological surgery and from multiple spine-focused specialty societies. Conclusion The future of spine surgery training will likely include dedicated categorical spine surgery residency programs,
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in addition to the option of pursuing spine surgery practice after orthopedic or neurological surgery residency training. Potential benefits of creating dedicated spine surgery residency training are numerous and will promote ongoing efforts to effectively train spine surgeons and improve patient care. It is clear that spine surgery continues to grow and is rapidly evolving into an independent medical specialty. At this juncture, we must ask ourselves: is it time for spine surgery to have its own residency training? References [1] ACGME program requirements for Graduate Medical Education in Neurological Surgery. Available at: http://www.acgme-i.org/web/ requirements/EmergencyMedicine.pdf. Accessed June 1, 2014. [2] ACGME program requirements for Graduate Medical Education in Orthopaedic Surgery. Available at: http://www.dconnect.acgme.org/ acWebsite/downloads/RRC_progReq/260orthopaedicsurgery07012007. pdf. Accessed June 1, 2014. [3] Daniels AH, DePasse JM, Magill ST, Fischer SA, Palumbo MA, Ames CP, et al. The current state of United States spine surgery training: a survey of residency and spine fellowship program directors. Spine Deformity 2014;2:176–85. [4] FREIDA Online graduates’ career plans search: orthopaedic surgery. Available at: https://freida.ama-assn.org/Freida/user/specStatisticsSearch. do?method5viewGraduates&spcCd5260&pageNumber53. Accessed October 22, 2013. [5] Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am 2014;96:e196. [6] Daniels AH, DiGiovanni CW. Is subspecialty fellowship training emerging as a necessary component of contemporary orthopaedic surgery education? J Grad Med Educ 2014;6:218–21. [7] FREIDA Online graduates’ career plans search: neurological Surgery. Available at: https://freida.ama-assn.org/Freida/user/specStatisticsSearch. do?method5viewGraduates&spcCd5160&pageNumber53. Accessed October 22, 2013. [8] Herkowitz HN, Connolly PJ, Gundry CR, Varlotta GP, Zdeblick TA, Truumees E. Resident and fellowship guidelines: educational guidelines for resident training in spinal surgery. Spine 2000;25: 2703–7. [9] Accreditation Council for Graduate Medical Education (ACGME) orthopaedic surgery case logs. National data report. 2012. [10] Accreditation Council for Graduate Medical Education (ACGME) neurological surgery case logs. National data report. 2012. [11] Dvorak MF, Collins JB, Murnaghan L, Hurlbert RJ, Fehlings M, Fox R, et al. Confidence in spine training among senior neurosurgical and orthopedic residents. Spine 2006;31:831–7. [12] Arnold PM, Brodke DS, Rampersaud YR, Harrop JS, Dailey AT, Shaffrey CI, et al; Spine Trauma Study Group. Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries and making assessment and treatment decisions: a multicenter reliability study. Am J Orthop (Belle Mead NJ) 2009;38:E156–61.
[13] Irwin ZN, Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, et al. Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine 2005;30:2208–13. [14] Irwin ZN, Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, et al. Variation in surgical decision making for degenerative spinal disorders. Part II: cervical spine. Spine 2005;30:2214–9. [15] Benzel EC. Reflections from a spine surgeon. CNS Quarterly 2012;13: 8–9. [16] Carreyrou J. Medicare records reveal troubling trail of surgeries. Wall St J 2011. [17] Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30:1441–5; discussion 1446–7. [18] Mincer J. Rate of spine surgery soars. Wall St J 2011. [19] Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009;22:62–8. [20] Herkowitz HN, Emery SE, Hurwitz SR, Harrast JJ. Performance of candidates selecting the subspecialty of spine surgery for the Part II American Board of Orthopaedic Surgery oral certification examination. J Bone Joint Surg Am 2013;95:e135. [21] Daniels AH, Grabel Z, DiGiovanni CW. ACGME accreditation of orthopaedic surgery subspecialty fellowship training programs. J Bone Joint Surg Am 2014;96:e94. [22] ACGME orthopaedic surgery minimum numbers. Available at: http:// www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/260_ ORS_Case_Log_Minimum_Numbers.pdf. Accessed June 1, 2014. [23] ACGME neurological surgery case log defined case categories and required minimum numbers. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PFAssets/ProgramResources/Final%20Defined %20Case%20Categories%20and%20Required%20Minimum%20 Numbers.pdf. Accessed June 1, 2014. [24] Baker P, Jameson S, Critchley R, Reed M, Gregg P, Deehan D. Center and surgeon volume influence the revision rate following unicondylar knee replacement: an analysis of 23,400 medial cemented unicondylar knee replacements. J Bone Joint Surg Am 2013;95:702–9. [25] Sooriakumaran P, Srivastava A, Shariat SF, Stricker PD, Ahlering T, Eden CG, et al. A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic, and robot-assisted radical prostatectomy patients. Eur Urol 2014;66: 450–6. [26] Lavernia CJ, Guzman JF. Relationship of surgical volume to shortterm mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty 1995;10:133–40. [27] Relles DM, Burkhart RA, Pucci MJ, Sendecki J, Tholey R, Drueding R, et al. Does resident experience affect outcomes in complex abdominal surgery? Pancreaticoduodenectomy as an example. J Gastrointest Surg 2014;18:279–85. [28] Booklet of information: vascular surgery. Philadelphia, PA: The Vascular Surgery Board of the American Board of Surgery, 2010– 2011. [29] Society for Vascular Surgery. Available at: http://www.vascularweb. org/studentsresidentstrainees/applytoprograms/Pages/VascularSurgery TrainingOptionsandPrograms.aspx. Accessed September 24, 2013. [30] American Board of Medical Specialties: approval of new member boards. Available at: http://www.abms.org/About_ABMS/ABMS_ History/Extended_History/Approving_New_Boards.aspx. Accessed December 21, 2013.
Perspective
Spine surgery training: is it time to consider categorical spine surgery residency? Alan H. Daniels, MDa,*, Christopher P. Ames, MDb, Steven R. Garfin, MDc, Christopher I. Shaffrey, MDd, K. Daniel Riew, MDe, Justin S. Smith, MD, PhDd, Paul A. Anderson, MDf, Robert A. Hart, MDg a Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley Street. Providence, RI 02905, USA Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave., Rm. M779, San Francisco, CA 94143, USA c Department of Orthopaedic Surgery, University of California San Diego, Perlman Ambulatory Care Center, 9350 Campus Point Drive, La Jolla, CA 92037, USA d Department of Neurological Surgery, University of Virginia, P.O. Box 800386, Charlottesville, VA, 22908, USA e Department of Orthopaedic Surgery, Washington University, Cervical Spine Institute. 4921 Parkview Place, A12, St. Louis, MO 63110, USA f Department of Orthopaedic Surgery, University of Wisconsin, 1685 Highland Ave., UWMFCB – 6215, Madison, WI 53705, USA g Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA b
Received 30 July 2014; accepted 17 August 2014
FDA device/drug status: Not applicable. Author disclosures: AHD: Trips/Travel: Stryker Spine (B, Paid directly to institution), DePuy/Synthes (A, Paid directly to institution). CPA: Royalties: Aesculap (C), Biomet Spine (E); Stock Ownership: Doctors Research Group (100 shares), Baxano Surgical (1,000 shares), Visualase (2,000 shares); Consulting: Medtronic (B), Stryker (B), DePuy (C). SRG: Royalties: DePuy Spine (I); Stock Ownership: Cross Tree (25,000 Shares), Interventional Spine (20,000 shares), Pioneer Surgical (10,000 shares, Consultant/speaker honoraria), Spinal Kinetics (10,000 shares), Spine Medica (25,000 shares), Surgifile (50,000 Shares), Cytonics Corporation (2,500 Shares), SI Bone, Inc. (200,000 shares); Consulting: Applied Spine Technology (B, Paid directly to institution/ employer), Magnifi Group (B, Paid directly to institution/employer), Cytonics (None), SI Bone, Inc. (A), Globus Medical (A), Benvenue Medical (C), NuVasive (D, Paid directly to institution/employer), Spinal Kinetics (None); Speaking/Teaching Arrangements: DePuy (Financial, reimbursement for travel and time), Biomet (Financial, reimbursement for travel and time); Board of Directors: Spine Arthroplasty Society (Financial, hotel reimbursement); Scientific Advisory Board: NuVasive (C, Paid directly to institution/employer), Spinal Kinetics (None), Spine Medica (None), Vertiflex (None), SI Bone, Inc. (None), Benvenue Medical, Inc. (B); Research Support - Staff/Materials: DePuy, Inc. (D, Paid directly to institution/employer), EBI (D, Paid directly to institution/employer), Medtronics (E, Paid directly to institution/employer), NuVasive (E, Paid directly to institution/employer); Fellowship Support: Synthes Spine (E), DePuy (E), Medtronics (E), Biomet (D). CIS: Royalties: Medtronic (F, Paid directly to institution), Biomet (D, Paid directly to institution); Consulting: Biomet (C), Globus (C), Medtronic (D), Nuvasive (C), Stryker (B); Grants: National Institutes of Health (D, Paid directly to institution), Department of Defense (F, Paid directly to institution), AO (E, Paid directly to institution), Neurosurgery Research and Education Foundation (E, Paid directly to institution), NACTN (F, Paid directly to institution); Fellowship Support: NREF (E, Paid directly to institution), AO (E, Paid directly to institution), University of Virginia (E, Paid directly to institution). KDR: Royalties: Biomet, Medtronic (G); Stock Ownership: Amedica; Benvenue; Expanding Orthopedics; Nexgen Spine; Spinal Kinetics; Spineology; Vertiflex; PSD (F); Speaking and/or Teaching Arrangements: AOSpine; New England; Royalties: Biomet (F), Osprey (C), Medtronic (G); Stock Ownership: Amedica (B), Benvenue http://dx.doi.org/10.1016/j.spinee.2014.08.452 1529-9430/Ó 2015 Elsevier Inc. All rights reserved.
(C), Expanding Orthopedics (B), Nexgen spine (B), Osprey (C), Paradigm Spine (B), Spinal Kinetics (C), Spineology (B), Vertiflex (B), PSD (B); Speaking and/or Teaching Arrangements: AOSpine (Honorarium), NASS (Honorarium); Trips/Travel: AOSpine (reimbursement only), NASS (reimbursement only), SRS (reimbursement only), Broadwater (reimbursement only), Selby Spine (reimbursement only); Board of Directors: CSRS (Past-President, 2012-2013, unpaid position), Global Spine Journal (Deputy Editor, unpaid position), AOSpine (Chair-elect & Research Chair, International Board, paid position), NASS (unpaid position); Grants: AOSpine (B, Paid directly to institution), Cerapedics (A, Paid directly to institution), Medtronic (C, Paid directly to institution for FDA-IDE study); Fellowship Support: AOSpine (Paid directly to institution). JSS: Consulting: Biomet (D), Cerapedics (B), Nuvasive (0), Medtronic (B); Speaking and/or Teaching Arrangements: Biomet (D), Globus (C), DePuy (C), Nuvasive (C); Grants: DePuy/ISSGF (D, Paid directly to institution); Fellowship Support: NREF (E, Paid directly to institution), AO (E, Paid directly to institution). PAA: Royalties: Styrker (D); Stock Ownership: SI Bone (!1%), Pioneer surgical (!1%), Titan Surgical (!1%), Expanding orthopedics (!1%), Spactec (!1%); Consulting: Stryker (E), Pioneer surgical (B), Aescualp (C). RAH: Grant: International Spine Study Group Foundation (C, Current/Active Grants), Medtronic (F); Royalties: SeaSpine (E), DePuy (B); Stock Ownership: SpineConnect (C); Honoraria: DePuy (C); Consultancy: DePuy (C), Globus (B), Medtronic (C); Speaking and/or Teaching Arrangements: DePuy (C); Board of Directors: CSRC Board, ISSLS, ISSG Executive Committee; Patent: US-2010-0268230-A1: Method and Apparatus for Dens Fracture Fixation (Pending, no sales to date). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. No funding was obtained for this study. No funding was obtained in support of this work. The authors have no relevant financial conflicts of interest to disclose related to this work. * Corresponding author. Department of Orthopaedics, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA. Tel.: (401) 444-4030; fax: (401) 444-6182. E-mail address: [email protected] (A.H. Daniels)
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Introduction Spine surgeon training in the United States consists of either an orthopedic or a neurological surgery residency program followed by an optional spine surgery fellowship [1,2]. Currently, orthopedic spine surgeons receive limited exposure to spine surgery during residency, then the vast majority go on to complete a spine fellowship before beginning independent spine surgery practice [3–6]. Most neurological surgeons receive exposure to spine surgery throughout residency, and some may even focus their final year of residency training on spinal conditions but do not necessarily complete a spine fellowship before performing spine surgery in practice [3,7]. Despite published guidelines for spine surgeon training regardless of specialty [8], the two separate training models provide trainees with different spine surgery exposure in terms of case load and case variety [3,5,9,10] and result in different experience levels and decision-making skills in treating spinal disorders at the conclusion of residency training [11–14]. The specialty of spine surgery has expanded to become a much more vast and complex discipline in recent years. Ideally, spine surgeons would be expected to master nonoperative spinal care in addition to many surgical techniques before independent practice, now including minimal access surgery, anterior and posterior spinal instrumentation, deformity of both cervical and thoracolumbar spines, motion-preserving approaches, and a host of interbody fusion techniques. Although both specialties bring unique perspectives to the art and science of spine surgery, the current two distinct specialty pathway training models may not be the optimal environment for educating tomorrow’s spine surgeons as wide variations in training may be detrimental to surgeon quality and patient care. Orthopedic spine surgery and neurological surgery each have rich histories and strong traditions in caring for spinal disease and innovative treatments. However, neither discipline offers a spine surgical training pathway intentionally designed to provide optimal experience from the standpoint of the current spine surgical environment [3]. In the future, spine surgery may benefit by having its own residency training in an effort to improve spine surgeon training and improve the quality of spine care provided in the United States.
The current state of spine surgery Major surgical advancements in spine surgery have come from both orthopedic and neurological surgery disciplines [15]. In the last 30 years, new ways to approach, instrument, arthrodese, and correct deformity of the spine have been successfully developed. These innovations stemming from the two specialties have helped form a collaborative bond between the specialists, yet the relationship between the two has also been and continues to be adversarial at times [15]. This truth must be acknowledged by all if positive change is hoped for.
With partnering in the development of modern spinal surgery, the art and science of spine surgery have advanced. Some spine surgeons now subspecialize in minimally invasive spine surgery, cervical spine surgery, spinal tumor surgery, motion-preserving spine surgery, pediatric spine surgery, and spinal deformity surgery. Although the principles of spine surgery may be mastered by individuals, it is increasingly unlikely that an individual spine surgeon can master all aspects of spinal surgery. Learning the practice of spine surgery through the traditional orthopedic and neurological surgery pathways is becoming increasingly difficult, as duty hour and supervisory restrictions have been implemented, while the breadth of surgical techniques continues to expand rapidly. A second important acknowledgment is the recognition that neither of the current pathways was designed with the modern spine surgical practice in mind, and neither provides an optimal approach to mastery of that environment and skill set (operative and nonoperative) [3]. Unfortunately, spine surgeons have recently been criticized for performing too much spine surgery, and for performing poor quality spine surgery, both in the lay press and the scientific literature [16–19]. The reputation of spine surgery has been tarnished and will require improved care by spinal surgeons if it is to be repaired. An important first step is recognizing the need, and therefore the opportunity, to improve our training programs with the intent of improving practice patterns and patient care. An additional concern is the 28% failure rate on Step II of the American Board of Orthopedic Surgery for orthopedic spine surgeons, the highest of any orthopedic specialty [20]. This may be, in part, because of suboptimal training regarding spinal pathology during both residency and fellowship. Spine training: is the current model optimal? Is it optimal to have two separate paths in spine surgery training? It is possible that 1 year of spine training after an orthopedic surgery residency program is insufficient to master the operative and decision-making skills necessary to independently practice spine surgery for many trainees. Trainees at orthopedic surgery programs with highvolume spine divisions, who are interested in spine surgery early in residency training, may receive adequate exposure and education in spine surgery to be proficient at spine surgery after a 1-year fellowship. However, trainees at programs with low-volume spine divisions, or who have decided to pursue spine training late in residency, may be poorly prepared for spine fellowship and may still be ill prepared for independent spine practice after a 1-year fellowship. Additionally, there is a lack of standardization for spine surgery fellowships [21], thus providing further variation in the training process. Separately, is a 7-year residency program sufficient to gain surgical knowledge and independence in all aspects of neurological and spinal surgery? Neurological surgery
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residency prepares trainees to perform basic spine surgery, but spinal deformity surgery and complex spinal reconstruction likely require additional dedicated fellowship training [3], thus resulting in 8 or more years of postgraduate medical training. Is this a reasonable expectation for the next generation of spine surgeons? In the current model of spinal surgery training, neurological surgery residency typically provides a strong background in neurotrauma, intradural processes, cerebrospinal fluid management, central nervous system tumors, and minimally invasive approaches, whereas orthopedic surgery training may not provide adequate exposure to these topics (Table 1). In contrast, orthopedic surgery residency typically provides a strong background in bone physiology, bone and soft tissue healing, skeletal growth and development, biomechanics, peripheral joint arthrosis, material science of implants, and scoliosis, whereas neurological surgery may not provide adequate exposure to these topics. These differences in educational pathways may result in different approaches to spine care [11–14]. There are also inconsistencies in training both between and within each specialty in terms of nonoperative care of spinal pathology, and in education regarding the natural history, outcomes, and timing of surgical interventions. These differences in educational pathways result in differences in spine surgery practices [3,5]. It is reasonable to suggest that the ability to provide balanced exposure to all these topics during training would be better. In addition to different educational focuses between the specialties, the Accreditation Council for Graduate Medical Education (ACGME) case log data reveal a large amount of variation both within and between the specialties in terms of spine surgery case exposure [5]. For example, orthopedic surgery graduates average 160 spine surgery procedures completed during residency, whereas neurological surgery residents average 375 spine surgery procedures [5]. Additionally, there is substantial variability in spine surgery exposure within each specialty, with the greatest variability seen in instrumented procedures. For spinal instrumentation/arthrodesis procedures, there is a 13-fold difference between the top and bottom 10% of orthopedic surgery residents and an eightfold difference between the top and bottom 10% of neurosurgery residents [5]. Furthermore, differences exist between orthopedics and neurosurgery in terms of ACGME spine surgery minimum Table 1 Strengths in training for each specialty Orthopedic surgery
Neurological surgery
Bone physiology; bone and soft tissue healing Skeletal growth and development Biomechanics Peripheral joint arthrosis Material science of implants Scoliosis
Neurotrauma Intradural processes Cerebrospinal fluid management Central nervous system tumors Minimally invasive approaches Spine surgery exposure throughout residency
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case requirements. These minimums are strikingly different between the two specialties and are at levels that are likely far below the minimum needed to achieve proficiency. The ACGME has determined that orthopedic surgery residents should perform no fewer than 15 ‘‘spine decompression/posterior spine fusion thoracic or lumbar’’ procedures during residency. In contrast, neurological surgery residents are required to perform no fewer than 85 adult spinal procedures, five cervical spine traction procedures, and five pediatric spine procedures during residency [22,23]. Spine surgery residency We believe that a focused and structured spine surgery training pathway could improve the quality of spine training and thus improve the care of spine patients treated in the United States. There are robust data supporting the fact that subspecialty surgeons who perform high volumes of a specific procedure have improved outcomes over surgeons who perform lower volumes of the same procedure [24– 26]. Additionally, residents with greater exposure to complex surgical procedures tend to have lower complication rates [27]. Although we are not aware of data specific to spine surgery, it is logical to assume that spine specialty–focused providers have improved outcomes over spine providers who do fewer spine procedures or include spine surgery within a more broadly focused practice. Spine surgery residency would foster a spine-centric education, with the ultimate goal of a spine-specific practice, with an expected effect of improving patient outcomes. An optimal spine surgery training program would be efficient in its aim to train spinal surgeons, focused on useful skills and knowledge for surgeons who will dedicate their practice solely to spine surgery. The exposure would ideally provide adequate breadth of operative and nonoperative experience to trainees, while ensuring competency before the completion of training. If spine surgeons wish to develop their own categorical residency training, it is important to explore the experiences of other surgical specialties that have successfully split from their parent specialty to form their own residency training programs, such as vascular surgery. Vascular surgery training required completion of a general surgery residency, followed by a vascular surgery fellowship up until the year 2006. Vascular surgeons began the movement for separation from general surgery and for board certification in the 1970s with an investigation by a committee from the American Board of Surgery (ABS) [28]. In 1981, the ABS won approval from the American Board of Medical Specialties (ABMS) to offer a certificate in vascular surgery. Over 30 years later, in 2006, vascular surgery became a primary specialty of the ABS, and certification in general surgery was no longer a prerequisite for certification in vascular surgery. This created the option of vascular surgery residency training.
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Today, 5-, 6-, and 7-year training options exist to obtain vascular surgery training. These options include 5 years of dedicated vascular surgery residency training, 5 years of general surgery training with a 2-year vascular fellowship, in addition to a combination of 3 to 3 and 4 to 2 year options available as well [29]. These options allow trainees to choose whether they wish to be board certified in both general surgery and vascular surgery or just in vascular surgery. A similar model could be adopted in spine surgery, with a variety of training options, including a shortened primary orthopedic or neurological surgery residency, followed by a prolonged spine surgery fellowship. Trainees would still be able to pursue spine surgery fellowship after traditional ‘‘complete’’ orthopedic or neurological surgery residencies. This would allow spine surgeons who trained through the traditional paths to practice general orthopedics or neurosurgery, in addition to spine surgery, and to obtain board certification in their specialty. Trainees who complete spine surgery residency would be dedicated spinal surgeons, without sufficient training to perform general orthopedic or neurological surgery. A desirable institution for a spine surgery residency would have a wide breadth of spine surgery with exposure to basic spine surgery, minimally invasive, deformity, tumor, and traumatic spine conditions. Ideally, development would occur as a collaborative effort between the orthopedic surgery and neurological surgery spine divisions to promote a well-rounded educational experience.
In the future, there may be independent Departments of Spine Surgery that would facilitate an independent training program. Additionally, a Department of Spine Surgery could have a nonoperative division, focusing on the nonsurgical aspects of spine care, which would act to supplement spine surgeon resident training. This model already exists in many academic orthopedics departments, where divisions of Sports Medicine have fellowship-trained physicians in both primary care and orthopedic surgery. A spine surgery residency program would be designed to provide pertinent rotations to optimally train spine surgeons. This may vary from institution to institution based on local resources, although ACGME requirements would have to be developed. One proposal of how a spine residency rotation schedule might be structured is offered here to help drive the discussion (Table 2). In all rotations, a combination of outpatient and inpatient care would be available. When spine surgery residency is implemented, ongoing evaluation will be needed to examine its effectiveness at training tomorrow’s spine surgeons. Challenges of implementation: process of implementation The development of spine surgery residency will face numerous challenges and barriers. The political challenges associated with the development of a dedicated spine surgery training pathway are
Table 2 Proposed residency training schedule with knowledge goals for each rotation PGY1 General surgery TICU/SICU Physical medicine and rehabilitation Medicine Emergency room Anesthesia Thoracic surgery Otolaryngology Radiology PGY2 Orthopedic: trauma Orthopedic arthritis/arthroplasty Neuroradiology: interventional radiology Neurological surgery: trauma Neurological surgery: tumor Neurological surgery: intracranial, interventional Neurological surgery: ICU PGY3 Spine surgery: trauma Spine surgery: elective spine PGY4 Spine surgery senior resident PGY5 Spine surgery chief resident PGY6 (optional fellowship year through match) Advanced spine fellowship: deformity, MIS, tumor, pediatric spine, arthroplasty, etc
Knowledge gained/goals for rotation Fluid management, surgical principles Critical care Nonoperative spine care, rehabilitation principles Medical care Spine trauma, critical care, airway management Spinal anesthesia, airway management Thoracic approaches, chest tube management Cervical approaches, airway management Imaging, interventional spine techniques Extremity trauma, fracturecare Degenerative orthopedic disorders, tribology Advanced imaging, percutaneous techniques Neurotrauma Neuro-oncology Neurodegenerative disorders Neuro critical care Spinal trauma: operative and nonoperative Degenerative spinal conditions, deformity Surgical autonomy increased Increased responsibility appropriate to level of ability, transition to independent practice Advanced/subspecialized spine techniques
PGY, post graduate year; TICU, trauma intensive care unit; SICU, surgical intensive care unit; MIS, minimally invasive surgery.
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substantial. The structure of orthopedic and neurological surgery departments at many institutions may not easily accept a change in the status quo regarding their spine division and trainees. Additionally, spine surgeons’ assertion that the current training system was ‘‘good enough for me’’ may provide additional argument against a major change in current spine surgeon training, although it must be recognized that today’s training environment and training demands are not equivalent to those of yesterday. Potential economic barriers to spine residency training also exist. Training programs are financially costly to departments, and financial hurdles may provide additional challenges in spine surgeon training reform. Concerns regarding the loss of spine surgery revenues for departments will arise, and removing spine surgery revenue from orthopedic and neurological surgery departments may initially be perceived as detrimental. However, with the advent of spine surgery residency, spine divisions could still be part of both orthopedic and neurological surgery departments, with revenue shared between them. This would allow the hiring of the best spine surgeon candidates, regardless of training background. Even if departments support the development of spine residency, additional barriers from the ACGME may arise. A formal petition to the ACGME Board is needed to develop new specialties recognized by the ACGME, which will provide the opportunity to present the argument that spine training could be improved with dedicated spine surgery resident training. If the ACGME approves a spine surgery residency training pathway, accreditation standards would need to be developed. This would necessitate discussion and development of minimum standards during spine surgeon training, beyond the current standards set for orthopedic and neurological surgery. There is also concern that spine residency development may set a precedent for further subspecialization within the orthopedic and neurological surgery professions, which could decrease the available pool for general orthopedic and neurological surgery emergency call physicians. Although these concerns are valid, they certainly should not serve as a primary reason to prevent change in training, which will lead to substantial improvements in spine patient care. An important additional consideration is that board certification in orthopedic surgery and neurological surgery will not be available to spine surgery resident trainees. Thus, a universally accepted Board for Spine Surgery will be necessary for ensuring adequate training, knowledge, and commitment to lifelong learning. The American Board of Orthopedic Surgery or the American Board of Neurological Surgery may wish to develop the dedicated Spine Surgery Board Certification. According to the ABMS, there are several key criteria for creating new medical examining boards, all of which would need to be fulfilled by spine surgery if a dedicated board is to be created [30]:
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1. The differentiation of a new specialty must be based on major new concepts in medical science and represent a distinct and well-defined field of medical practice. 2. A single standard of preparation for, and evaluation of, expertise in each specialty must be recognized by only one medical specialty board for each specialty. 3. The training needed to meet certification requirements by the applicant must be distinct from that required for certification by approved ABMS Member Boards so that it is not included in established training programs leading to certification by approved ABMS Boards. 4. A medical specialty board must demonstrate that candidates for certification will acquire, and its’ diplomates will maintain capability in a defined area of medicine and demonstrate special knowledge and competencies in that field. 5. Evidence must be presented that the new board will establish defined standards for training and that there is a system for evaluation of educational program quality. 6. The applicant medical specialty board must demonstrate support from the relevant field of medical practice and broad professional support. Discussion The current model of training has provided society with a group of highly skilled spinal surgeons. However, the world is changing around us, and the old model of training is no longer the most efficient and effective strategy for training tomorrow’s spine surgeons. Change in medicine can be a challenging process. However, we should consider that progress in our field must be pursued for the benefit of both patients and trainees. There is a need for a deliberately designed, efficient, spine surgery training pathway to improve spine surgeon training and thus spine patient care. Numerous major changes to medical practice and training, such as acceleration in pay for performance strategies, medical informatics, quality initiatives, competency-based learning, virtual classrooms, and haptic motor simulation strategies, are being implemented. Surely, these initiatives should carry over into efforts to optimize training programs, even if initially disruptive to current practitioners and teachers. To move this discussion forward, an exploratory committee should be developed to examine the issue of spine surgeon training reform. Members of this committee should come from both orthopedic and neurological surgery and from multiple spine-focused specialty societies. Conclusion The future of spine surgery training will likely include dedicated categorical spine surgery residency programs,
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in addition to the option of pursuing spine surgery practice after orthopedic or neurological surgery residency training. Potential benefits of creating dedicated spine surgery residency training are numerous and will promote ongoing efforts to effectively train spine surgeons and improve patient care. It is clear that spine surgery continues to grow and is rapidly evolving into an independent medical specialty. At this juncture, we must ask ourselves: is it time for spine surgery to have its own residency training? References [1] ACGME program requirements for Graduate Medical Education in Neurological Surgery. Available at: http://www.acgme-i.org/web/ requirements/EmergencyMedicine.pdf. Accessed June 1, 2014. [2] ACGME program requirements for Graduate Medical Education in Orthopaedic Surgery. Available at: http://www.dconnect.acgme.org/ acWebsite/downloads/RRC_progReq/260orthopaedicsurgery07012007. pdf. Accessed June 1, 2014. [3] Daniels AH, DePasse JM, Magill ST, Fischer SA, Palumbo MA, Ames CP, et al. The current state of United States spine surgery training: a survey of residency and spine fellowship program directors. Spine Deformity 2014;2:176–85. [4] FREIDA Online graduates’ career plans search: orthopaedic surgery. Available at: https://freida.ama-assn.org/Freida/user/specStatisticsSearch. do?method5viewGraduates&spcCd5260&pageNumber53. Accessed October 22, 2013. [5] Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am 2014;96:e196. [6] Daniels AH, DiGiovanni CW. Is subspecialty fellowship training emerging as a necessary component of contemporary orthopaedic surgery education? J Grad Med Educ 2014;6:218–21. [7] FREIDA Online graduates’ career plans search: neurological Surgery. Available at: https://freida.ama-assn.org/Freida/user/specStatisticsSearch. do?method5viewGraduates&spcCd5160&pageNumber53. Accessed October 22, 2013. [8] Herkowitz HN, Connolly PJ, Gundry CR, Varlotta GP, Zdeblick TA, Truumees E. Resident and fellowship guidelines: educational guidelines for resident training in spinal surgery. Spine 2000;25: 2703–7. [9] Accreditation Council for Graduate Medical Education (ACGME) orthopaedic surgery case logs. National data report. 2012. [10] Accreditation Council for Graduate Medical Education (ACGME) neurological surgery case logs. National data report. 2012. [11] Dvorak MF, Collins JB, Murnaghan L, Hurlbert RJ, Fehlings M, Fox R, et al. Confidence in spine training among senior neurosurgical and orthopedic residents. Spine 2006;31:831–7. [12] Arnold PM, Brodke DS, Rampersaud YR, Harrop JS, Dailey AT, Shaffrey CI, et al; Spine Trauma Study Group. Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries and making assessment and treatment decisions: a multicenter reliability study. Am J Orthop (Belle Mead NJ) 2009;38:E156–61.
[13] Irwin ZN, Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, et al. Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine 2005;30:2208–13. [14] Irwin ZN, Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, et al. Variation in surgical decision making for degenerative spinal disorders. Part II: cervical spine. Spine 2005;30:2214–9. [15] Benzel EC. Reflections from a spine surgeon. CNS Quarterly 2012;13: 8–9. [16] Carreyrou J. Medicare records reveal troubling trail of surgeries. Wall St J 2011. [17] Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30:1441–5; discussion 1446–7. [18] Mincer J. Rate of spine surgery soars. Wall St J 2011. [19] Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009;22:62–8. [20] Herkowitz HN, Emery SE, Hurwitz SR, Harrast JJ. Performance of candidates selecting the subspecialty of spine surgery for the Part II American Board of Orthopaedic Surgery oral certification examination. J Bone Joint Surg Am 2013;95:e135. [21] Daniels AH, Grabel Z, DiGiovanni CW. ACGME accreditation of orthopaedic surgery subspecialty fellowship training programs. J Bone Joint Surg Am 2014;96:e94. [22] ACGME orthopaedic surgery minimum numbers. Available at: http:// www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/260_ ORS_Case_Log_Minimum_Numbers.pdf. Accessed June 1, 2014. [23] ACGME neurological surgery case log defined case categories and required minimum numbers. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PFAssets/ProgramResources/Final%20Defined %20Case%20Categories%20and%20Required%20Minimum%20 Numbers.pdf. Accessed June 1, 2014. [24] Baker P, Jameson S, Critchley R, Reed M, Gregg P, Deehan D. Center and surgeon volume influence the revision rate following unicondylar knee replacement: an analysis of 23,400 medial cemented unicondylar knee replacements. J Bone Joint Surg Am 2013;95:702–9. [25] Sooriakumaran P, Srivastava A, Shariat SF, Stricker PD, Ahlering T, Eden CG, et al. A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic, and robot-assisted radical prostatectomy patients. Eur Urol 2014;66: 450–6. [26] Lavernia CJ, Guzman JF. Relationship of surgical volume to shortterm mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty 1995;10:133–40. [27] Relles DM, Burkhart RA, Pucci MJ, Sendecki J, Tholey R, Drueding R, et al. Does resident experience affect outcomes in complex abdominal surgery? Pancreaticoduodenectomy as an example. J Gastrointest Surg 2014;18:279–85. [28] Booklet of information: vascular surgery. Philadelphia, PA: The Vascular Surgery Board of the American Board of Surgery, 2010– 2011. [29] Society for Vascular Surgery. Available at: http://www.vascularweb. org/studentsresidentstrainees/applytoprograms/Pages/VascularSurgery TrainingOptionsandPrograms.aspx. Accessed September 24, 2013. [30] American Board of Medical Specialties: approval of new member boards. Available at: http://www.abms.org/About_ABMS/ABMS_ History/Extended_History/Approving_New_Boards.aspx. Accessed December 21, 2013.