Spine surgery education may benefit from integrative specialty training

Orthopedic spine surgeons and spine-focused neurosurgeons have traditionally trained separately during their residencies and fellowship programs. However, the overlap of spine procedures performed by both orthopedic surgeons and neurosurgeons is increasing to the extent that there may now be more of a rationale for combined orthopedic surgery and neurosurgery spine residencies and fellowships.

Training programs overlap in all types of specialties, so the possibility of an orthopedic spine and neurosurgery partnership may be beneficial, according to Sanford E. Emery, MD, MBA, of West Virginia University.

“Things change in every profession, including ours, and in the different subspecialties. I have seen some of the history and the changes in the last 25 years with respect to orthopedic spine and neurosurgery spine. Things have converged a lot with what we do, such as approaches to patients, breadth of training and treatment options. That has all been a good change. The two subspecialties, and I think in most places, work pretty well together,” Emery told Spine Surgery Today.

Greater overlap in specialties

The overlap of spine procedures being performed by both neurosurgeons and orthopedic surgeons is rapidly expanding. If you picture the two in a Venn diagram, Emery said, the overlap in their similarities is much larger than the differences between the two specialties.

Many institutions now offer unique spine fellowships that encompass both orthopedic and neurosurgery spine procedures to give surgeons a breadth of experience for both fields. Keck School of Medicine of University of Southern California (USC), for instance, offers a combined spine fellowship that has seen some success, Emery said.

The fellowship is 1 year and focuses on spine surgery training. Fellows participate in all areas of clinical spine, including cervical, thoracic, lumbar and degenerative and deformity diagnoses, while at the same time working with the attending physicians at the USC Spine Center.

Rotations in both specialties

West Virginia University, for example, also has several orthopedic surgery fellows who now take rotations in the neurosurgery department, Emery said.

Integrative fellowships, like at the Keck School of Medicine, are slowly becoming more common, but combining the specialties to create a spine surgery residency program may not be the best idea, he said.

“I do not want to become just a technician. For example, cardiologists working on the patient provide a diagnosis, and then hand them over the cardiac surgeons who just operate. That is a little different, but I am not sure that is a model we want to evolve into. That would be a whole paradigm shift,” Emery said.

Hyper-specialization a concern

Becoming too hyper-specialized may be a detriment to surgeons practicing today, according to Emery. For example, a patient presenting to a physician with pain may have to go to several subspecialists to determine the proper diagnosis for their ailment.

“It is crazy and a waste of a patient’s time and resources. You can get too subspecialized. Patients do not always come in with a diagnosis. They do not always come in with an MRI that has been done, but they often come in with pain. The better I am at diagnosis and treatment options, the more value I offer for these given patients. There is value in that, having a broader background of experience,” Emery said.

Currently, training for spine surgery in both the orthopedic and neurosurgery specialties offers tremendous opportunity to become immersed and proficient in the latest technological advances and new procedures in the field of spine surgery., Emery said. Spine surgery trainees experience more than sufficient exposure to the newest techniques and procedures, he noted.

“As surgeons, we know things evolve, procedures evolve, and several of the procedures I do now on a regular basis did not exist when I was training. But, if I am a good surgeon, I know the anatomy and I have trained for various techniques. Then, I can adapt and pick up new technology to various degrees. [With] the best fellowship programs, they are well-schooled in everything,” Emery said.

Separate training is best

There are benefits to the traditional training methods of orthopedic spine surgeons and spine-focused neurosurgeons, and elimination of the two tracks may prove to be detrimental to patients, Daniel K. Resnick, MD, a neurosurgeon at University of Wisconsin, in Madison, Wisc., told Spine Surgery Today.

Spine-focused neurosurgeons currently have training that is focused on microsurgery, treatment of tumors and minimally invasive surgical techniques, whereas orthopedic spine surgeon training has a greater history of biomechanics, respect for long-standing principles and a longer history of instrumentation, he said.

By combining the two, according to Resnick, it is possible some viewpoints will become narrower with time and solutions to problems could become more limited.

“From an intellectual standpoint, you have two groups of people coming at a problem from different viewpoints. This has significantly benefited spine surgery in terms of the crosstalk between the specialties, to a great extent. Even today, I work with a group of great orthopedic surgeons at the University of Wisconsin, and when we have conferences, we will have differences of opinion regarding how best to accomplish certain goals that you can trace back to our training. Nobody is wrong and there are different ways to approach different problems,” he said.

Shortened training time

There are substantial benefits to “cross-pollination between the specialties,” but there are important economic realities and practical realities related to call coverage in hospitals and the identities of orthopedics and neurosurgery, as specialties, in their own right, Resnick said.

He said the only benefit to a combined training would be the possibility of a shortened training period for residents. If a resident is purely focused on spine, he or she would not have to “necessarily spend time in a critical care unit or have to learn how to do hips,” which would make it a shorter program, Resnick said.

“What would ultimately suffer is that loss of transference of skills from different parts of orthopedics and neurosurgery training that you generally can only apply to the spine,” he said.

If the two were ever to be integrated, the spine residency also would have to include aspects of physical therapies and non-traditional medicine because if you are going to create spine physicians, then they need to be familiar with delivering a wide breadth of care, Resnick said.

Benefits of a spine specialty

Frank J. Schwab, MD, of Hospital for Special Surgery, in New York City, said there is a benefit to creating a specific spine surgery specialty since both specialties have more overlap now than before. It may make sense to have a combined neurosurgery and orthopedic residency program dedicated to just the spine or perhaps two shortened, separate opportunity to participate in a longer fellowship, he said

“The strong argument for combining them is the fact that more of what we consider spine surgery and advanced spinal surgical training overlaps completely between spine surgery and neurosurgery. There is possibly a past tradition to keep those fields along clean, separate lines, but now we recognize we are treating these with more openness and saying we should all be working together and training together,” Schwab told Spine Surgery Today.

Dedication to spine

Schwab said there are now many orthopedic surgeons and neurosurgeons who are board certified in both specialties. Many trainees decide to participate in both orthopedic and neurosurgeon residency programs to ensure their education is expansive.

A unique spine residency program may make sense for a trainee who is sure he or she wants to be dedicated to spine, but this would not make sense for someone who will practice in an area of the United States or the world where there is a need to be more well-rounded, he said.

“Hyper-specialization has its advantages, but has its drawbacks, as well. You lose out on other aspects of training that would like you to treat pathologies outside of the spine,” Schwab said.

80-hour limit not affected

Combined training would not have to run afoul of the 80-hour work week limit for trainees set by the Accreditation Council for Graduate Medical Education for residents throughout all medical specialties. Those limits are important for patient safety, and to overcome the work hour restrictions, instead of working more hours during a week or during a day, the training period for a spine residency program might be longer than what is traditional for an orthopedic or neurosurgery residency, Schwab said.

It is important, he said, to maintain the 80-hour work week threshold for safety reasons.

“Maybe [they] do not need more hours per week, but a longer period of training before becoming completely independent and treating patients on their own,” Schwab said.

The Journal of the American Medical Association published a study in 2007 that found 2 years after the 80-hour work week was imposed in 2003, significant improvements were made in patient mortality at U.S. Veterans Administration teaching hospitals, which underscores the association between reduced work hours and increased safety.

Dual residencies

One possibility to consider is a scenario where a trainee participates in separate orthopedic and neurosurgery residencies.

Christopher I. Shaffrey, MD, of the University of Virginia, told Spine Surgery Today he completed residences in both neurosurgery and orthopedics.

“From an orthopedic perspective, a lot of people, through the course of their training, have an emphasis on biomechanics, biomaterials and bioengineering. A lot of the emphasis of neurosurgery, outside of the spine, is neuro-regeneration, vascular pathology and different things like that. Basically, there are important things to learn from the experiences both from the neurosurgery perspective and orthopedic perspective,” he said.

Shaffrey noted that in 1984, during his training, he felt as if participating in both residencies was the only course that would result in an overall education in the spine. He said overall training is better now and the collaboration between orthopedic surgeons and neurosurgeons is far greater than what existed when he was being trained.

“With combined fellowships, I think that does give a broader overall exposure than, for example, going someplace and working with one or two individuals who are highly focused on a particular specialty or subspecialty,” he said.

Training will continue to evolve and in 20 years either orthopedic or neurosurgery departments may offer general training for 4 years and then an additional 2 years of training in spine, Shaffrey said. After that, an additional year of training in subspecialties related to spine techniques, such as minimally invasive surgery, advanced reconstructive procedures or advanced oncological surgical procedures, may be offered to trainees, he said.

Hurdles to reality

Although the premise of a combined orthopedic and neurosurgery residency program may offer its advantages, there are also several hurdles that must be climbed before this becomes a reality, according to Bernard R. Bendok, MD, chair of the neurosurgery department at the Mayo Clinic, in Scottsdale, Ariz.

The creation of a residency for a spine specialty would be a difficult task. Combined fellowship programs have faced obstacles with their creation, and a unique spine residency would likely face similar hurdles, he said.

“I think, as they say, ‘The devil is always in the details.’ How do you structure it? Who pays for it? Who covers the cost? What is the curriculum? What is the governing body? Who signs off on the fellowship? Working out the details is the challenge, and orthopedic surgeons answer to a different body than neurosurgeons in terms of national training and so on,” Bendok told Spine Surgery Today.

Combining fellowships will only be possible at a hospital where the faculty is of high quality, Bendok said.

Online education a possibility

One possibility for the future of orthopedic spine surgeon and spine-focused neurosurgeon training would be the collaboration of online education across the two specialties.

By simply collaborating in online education, they would forgo the process of creating an entirely unique spine residency or combined neurosurgery and orthopedic fellowship focusing on the spine, according to Bendok.

“While standardizing everything is not possible or even desirable, there are some things one can standardize, such as establishing a curriculum with online lectures where every spine fellow has access to all education. This has been a pursuit not just in spine surgery, but in all of resident and fellowship training. How do you make sure the content of training is not so much dependent on local strengths and weakness? I think that is an area where one could start, by standardizing a curriculum and standardizing educational content and creating new tools for fellows,” Bendok said.

It may eventually come down to appreciating how best to celebrate diversity of background, while at the same time embracing standardization. This, Bendok said, will be a challenge for medical education moving forward. – by Robert Linnehan

• References:
• Volpp KG, et al. JAMA. 2007;doi:10.1001/jama.298.9.984.
• Keck School of Medicine of USC. USC Department of Orthopaedic Surgery. USC Spine Fellowship. 2015. Available at: http://keck.usc.edu/Education/Academic_Department_and_Divisions/Department_of_Orthopaedic_Surgery/Education_and_Training/Fellowships/USC_Spine_Fellowship.aspx. Accessed Dec. 14, 2015.

• For more information:
• Bernard R. Bendok, MD, can be reached at Mayo Clinic, Department of Neurosurgery, 5777 E. Mayo Blvd. 5E, Phoenix, AZ 85054; email: bendok.bernard@mayo.edu.
• Sanford E. Emery, MD, MBA, can be reached at Department of Orthopaedics, West Virginia University School of Medicine, 1 Stadium Dr., Morgantown, WV 26505; email: semery@hsc.wvu.edu.
• Daniel K. Resnick, MD, can be reached at Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI 53726; email: resnick@neurosurgery.wisc.edu.
• Frank J. Schwab, MD, can be reached at Hospital for Special Surgery, 523 East 72nd St., New York, NY 10021; email: schwabf@hss.edu.
• Christopher I. Shaffrey, MD, can be reached at PO Box 800386, Charlottesville, VA 22908-0212; email: cis8z@hscmail.mcc.virginia.edu.

Disclosures: Bendok reports he is the chair of neurosurgery and chair of the education committee at the Mayo Clinic in Arizona. Resnick reports he is a past president of the Congress of Neurological Surgeons and current vice president of the North American Spine Society. Schwab reports he is on the board of the Scoliosis Research Society and the International Spine Study Group. Emery and Shaffrey report no relevant financial disclosures.

Do spine surgery trainees get taught enough about indications and nonoperative management to balance their technical training? 

 

Most have solid training foundation

The training for spine surgery involves either an orthopedic or neurosurgery residency, with advanced training in the treatment of spinal disorders during residency or in a postgraduate fellowship. Frequently, this training encompasses care for patients with spinal pathologies both in the OR and outside of the operative theater during perioperative management. The Residency Review Committee and the specialty-specific medical boards have requirements not only surrounding case volume, but also outpatient clinic time to understand operative indications.

Discussion surrounding nonoperative management during spine surgery training comes in forms of established literature, direct mentorship from preceptors and educational conferences from medical leaders. Most spine surgeons who have completed their training are knowledgeable regarding nonoperative management of frequently encountered spinal pathologies, for example lumbar radiculopathy without motor weakness or cervical radiculopathy without neurologic deficit. Furthermore, most have a solid understanding of the indications and timing of interventions for common surgical pathologies, for example, lumbar spinal stenosis causing cauda equina and acute cervical myelopathy.

The challenge many spinal surgeons face is the approach to many pathologies involving the spine should intervention be required. The acute thoracic disc or the acute cervical disc causing radiculopathy have multiple treatment options depending on the technical skill of the operator. That being said, the knowledge of when to operate is provided by the graduated responsibility during spine surgery training. Limitations do exist within the training, as not all surgeons are educated to the multitude of modalities of nonoperative management that exist. However, most of training programs provide a solid foundation of spine surgery clinicians.

Jamal McClendon Jr., MD, is a pediatric neurosurgery fellow at Phoenix Children’s Hospital in Phoenix.

Disclosure: McClendon reports no relevant financial disclosures.
 

 

Taught during office hours

Technical training in spinal surgery is often what trainees are most concerned about when choosing a training program. Although this is an important part of training, it is almost impossible for a trainee to learn all of the technical aspects of spinal surgery during residency and fellowship training. This is because the technical aspects of what we do are constantly being improved upon and can vary depending on a given surgeon’s experience and preference.

Indications and when “not to operate” on a patient, however, is something trainees must learn during training, and the best residencies and fellowships place as much emphasis on this aspect of training. Indications and nonoperative management are often discussed during a surgical procedure, or in the short period of time before or after the procedure, but this is not where these aspects are best taught or learned.

In our training program, for example, residents and fellows spend at least one full day every week in the office seeing patients side by side with an attending physician. It is during these office hours in which trainees learn indications and the art of discussing surgical and nonsurgical options with patients. It is here that trainees learn that medicine is truly an art and not a science. It is here that trainees learn that setting the right expectation for patients and allowing them to make an educated decision as to what their treatment should be results in the best outcomes.

As we train our future spine surgeons, it is critical to remember we must take the time to allow them to participate in office hours seeing patients, new and established, preoperative and postoperative. It is here where they will learn the art of taking care of the spine patient and providing the most appropriate care to meet a patient’s individual needs.

Sheeraz A. Qureshi, MD, is an associate professor of orthopedics at Mount Sinai Hospital in New York.

Disclosure: Qureshi reports no relevant financial disclosures.

 

Sufficient exposure to nonoperative care, indications

The management of symptomatic spinal pathology accounts for more than 50% of the scope of practice of neurosurgeons in the United States. Neurosurgical training in spinal surgery starts at the beginning of residency and continues throughout training. Roughly half of the clinical time in this 7-year residency is devoted to the operative and nonoperative management of spinal pathology. As with most surgical disciplines, the focus is heavily weighted toward the operative experience and preoperative and postoperative care in hospital. Outpatient clinic experience focuses on both nonoperative management and the appropriate selection of patients for elective surgical interventions.

Nonoperative management is taught in the clinical setting and also within the hospital. Numerous emergency treatment facility consults consist of patients with nonoperative spinal conditions and the same is true of in-house consultations, both of which supplement the outpatient experience. Each resident is required to achieve a defined level of competency as delineated by the Accreditation Council for Graduate Medical Education (ACGME) Milestones, which includes both operative and nonoperative care and indications for a wide range of spinal surgery. This process ensures the finishing resident has a comprehensive understanding of the broad field of spine care.

Upon completion of residency training, every neurosurgeon is fully grounded in all of the aspects of spinal surgery including both operative and nonoperative subsets. All residents will have been trained to evaluate and surgically manage the entire spectrum of degenerative, deformity, oncologic and traumatic spinal conditions. Fellowship training is available for those who wish to focus primarily on specific aspects of complex spinal surgery which may include spinal column and cord injury, biomechanical or neuroregenerative research, management of complex deformities, spinal oncology and cutting-edge minimally invasive techniques. As spinal surgery training is so integral to neurosurgery residency, the ACGME does not recognize neurosurgical spinal fellowship programs. To assure quality in such programs, the Senior Society of Neurological Surgeons formed the Committee on Advanced Subspecialty Training which reviews and accredits spinal fellowship programs using rigorous criteria to ensure that a quality experience is provided. These fellowships also provide exposure to nonoperative management and indications for complex spinal surgery.

Vincent C. Traynelis, MD, is a Spine Surgery Today Editorial Board member. He is at Rush University Medical Center in Chicago.

Disclosure: Traynelis is a consultant to and receives royalties from Medtronic, and he receives institutional fellowship support from Globus and AO.