Subspecialty certification

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Wilberger et al

Surg Neurol 1997;47:403-11

sible malpractice suit. Later the objection was that if pediatric neurosurgery was given such recognition, other subspecialties such as spine surgery, trauma, tumor, and stereotactic radiosurgery, as examples would demand special certificates of competence in their special fields. Pediatric neurosurgery needs to and wants to remain under the umbrella of neurosurgery but the development of special skills in pediatric neurosurgery and in pediatrics indicates that subspecialization is essential. To return to the comment by the distinguished physician, Dr. Shattuck, in the present day it would defy logic to refuse independent boards to obstetrics and pediatrics just as it is now illogical to refuse to allow pediatric neurosurgery to remain in neurosurgery but be granted certificates of special competence. For over thirty years pediatric neurosurgery has proposed that after an individual completes a full neurosurgical residency he/she may elect to take one or more years at one of a small number of recognized pediatric neurosurgical centers in the United States or Canada, after which the certification of special competence might be granted. Eben Alexander,

Jr. M.D.

Department of Neurosurgery Wake Forest University Winston-Salem,North Carolina Should subspecialty certification be pursued by the American Board of Neurological Surgery? In short, no, as one union card is enough to practice neurosurgery in America. To require subspecialty certification for the practice of neurosurgery would require increased post-residency training with fellowships. While this might increase the labor force for neurosurgical programs, it most certainly would decrease the hands-on training of the Chief Resident and Senior Resident, as their cases would be “passed” to the now superiorly ranked fellow or fellows (no program worth its salt would have just one fellow). This would only aggravate the present training problem of neurosurgery programs, as the wealth of neurosurgical disease is now spread thinly across multiple surgical practices, both academic and private. This is not to say that subspecialization does not have its place in neurosurgery. Almost every practice with more than one neurosurgeon develops specialty of expertise within itself, where one individual will do the pediatrics and another will do the stereotactic frame or more spine work, and so on. Certainly the development of postgraduate courses in the subspecialties has been a very positive on-

going event. It has done much to educate the practicing neurosurgeon about the new developments in neurosurgery. But I do notice that these courses have just as many older practicing neurosurgeons attending as they do young neurosurgeons fresh from residency. One would think that if they were adequately trained, these young neurosurgeons would not need to take these courses. Lastly, from a more cynical perspective, academia’s support of specialty certification is a means of maintaining their market share of patients in the face of dwindling numbers of cases caused by managed care organizations diverting them away from universities. After all, if you don’t have a subspecialty union card, you are not qualified (allowed) to do the work. Henry

M. Shuey, Jr., M.D.

Neurosurgeon Baltimore, Maryland Neurosurgical residency programs should train neurosurgical residents so that upon finishing their programs, residents are fully trained as spine surgeons. If residents then forego a fellowship and wish to subspecialize in spine in their practices, they would be qualified to do so. One might then argue why a spine fellowship is needed. I believe spine fellowships are important because they emphasize neurosurgery’s commitment to spine within that institution, the training program, the community, and nationally. Fellowships should develop “supersubspecialists” who become leaders in the area of spine with extra experience clinically as well as in the laboratory. Spine fellowships are also needed because although many resident training programs have enough complex spine cases from which residents can learn, some do not. Neurosurgeons who have completed a spine fellowship can then fill the void in a faculty otherwise lacking spine specialists, so that residents are exposed to such complex cases. Consequently, the role of the neurosurgical residency program is to train residents to become fully competent spine surgeons, but fellowships in spine should exist to develop the supersubspecialty and leaders in the field. Once a subspecialty is established, the question of subspecialty certification naturally arises. It is well known that neurosurgery has been hesitant to approve recertification or subspecialty certification. Subspecialty certification is definitely problematic. It would fragment the discipline of neuro surgery, which, as it is now perceived by our colleagues, would be irrevocably changed. Consequently, at this time, I do not support subspecialty