Variability in Resident Operative Hand Experience by Specialty

Impact of Orthopedic Hand Surgery Fellowship Training on Hand Surgery Cases Performed by Plastic Surgeons in the United States

Objective

Multiple pathways exist for hand surgery training in the United States. Plastic surgeons often select Orthopedic Hand Surgery Fellowships to complement their skills and bridge perceived deficiencies in bone and joint cases. This study aims to quantify the impact of this approach on operative hand experience.

Materials and methods

Case logs were analyzed for plastic surgery residents and orthopaedic hand surgery fellows (2016-2017 to 2019-2020). Reported hand surgery cases were compared between residency and fellowship using Student's t-tests. In total, 606 plastic surgery residents and 393 orthopaedic hand surgery fellows were included in this study. One year of Orthopedic Hand Surgery Fellowship training afforded more than twice the volume of hand surgery cases than Plastic Surgery Residency training (886.1 ± 234.7 vs. 428.1 ± 147.2, p < 0.001).

Results

Case categories with the greatest positive fold difference in case volume encountered during Orthopedic Surgery Hand Fellowship were tumor (138.2 ± 63.2 vs. 22.1 ± 11.8, p < 0.001), joint reconstruction (108.7 ± 21.6 vs. 18.8 ± 11.5, p < 0.001), nerve decompression (158.4 ± 63.1 vs. 53.0 ± 32.6, p < 0.001), Dupuytren's (18.4 ± 10.5 vs. 7.6 ± 6.4, p < 0.001), and fracture management (132.8 ± 21.7 vs. 59.6 ± 24.1, p < 0.001).

Conclusion

Orthopedic Hand Surgery Fellowship training doubles the operative hand case volume encountered during Plastic Surgery Residency. Significant increases are especially encountered for select case categories including bone and joint cases.

Educational and Clinical Outcome Measures in an Integrated Hand Service

Background

We recently sought to integrate our orthopaedic and plastic hand surgeons with the goal of improving education, patient care, and providing seamless, continuous coverage for our trauma center. Our hypothesis was that integration could serve both the orthopaedic and plastic surgery training programs well and provide more consistent care for the trauma patients.

Materials and Methods

Program director approval was granted for blinded analysis of case logs from plastic and orthopaedic surgery programs from 2012 through 2019. Data on mean and total number of hand cases were analyzed and compared for both specialties. Institutional Review Board approval was granted for a retrospective review of patient outcomes.

Results

For both orthopaedic and plastics resident trainees, the mean number of hand cases increased during this study period suggesting that the integration had a favorable impact on both programs. The mean number of hand cases for orthopaedic residents rose from 163 to 246. The mean number of hand cases for plastic surgery residents rose from 218 to 295. Patient outcomes as reflected in length of stay and time to consultation also improved.

Conclusion

To improve hand surgical training and patient care, an integrated orthoplastics approach to hand surgery was implemented at our institution. Plastic surgery trainees are completing more hand surgery cases in an integrated model (p < 0.001), including fracture care (p < 0.047). Orthopaedic surgery trainees have doubled the percentage of integumentary and microsurgery cases in the integrated model (p < 0.001). The educational and clinical changes affected in an integrated model have changed the paradigm for educating future hand surgeons at our institution.

Charting Outcomes in the Hand Surgery Fellowship Match

PURPOSE

The hand surgery fellowship match attracts applicants from general, plastic, and orthopedic surgery residency training. The purpose of this study was to understand recent trends in applications and match rates in the hand surgery fellowship match.

METHODS

The National Resident Matching Program provided program and applicant data from the hand surgery fellowship match (2012-2020). The primary outcomes of interest were match rates and number of unfilled fellowship positions by specialty. Trends over time and comparisons of the percentage of unfilled spots by specialty were observed.

RESULTS

The total number of applicants decreased from 199 to 188 (5.5% decrease), while the number of available positions increased from 150 to 177 (18.0% increase) during the study period. The increase in available positions was driven primarily by orthopedic fellowships, which increased from 124 to 149 (20.2% increase). The percentage of applicants that did not match to a hand surgery fellowship decreased from 24.6% in 2012 to 5.9% in 2020. United States graduates had higher match rates than non-United States graduates during each year, but this disparity narrowed over time. Most applicants matched at one of their top 3 choices (first choice, 33.3%; second choice, 12.9%; third choice, 7.9%). Applicants matching at their first choice increased from 28.1% in 2012 to 39.4% in 2020. Plastic surgery hand surgery fellowships had a higher rate of unmatched positions relative to orthopedic surgery fellowships (6.1% vs 2.2%).

CONCLUSIONS

Match rates in the hand surgery fellowship match have increased because of an overall increase in training positions and decrease in applicants. More research is needed to understand disparities in match rates by specialty.

CLINICAL RELEVANCE

The diverse training experiences of hand surgeons historically have been viewed as a strength for the specialty. Understanding recent trends in the hand surgery fellowship match by specialty can help future applicants and faculty anticipate likely match outcomes.

Analysis of Strengths in Exposure to Cases During Plastic and Orthopaedic Hand Surgery Fellowships

INTRODUCTION

Prospective residents interested in hand surgery must decide to apply for hand surgery fellowships sponsored by different specialties. This study compares case volumes reported during plastic surgery and orthopaedic hand surgery fellowships.

METHODS

The American Council for Graduate Medical Education case logs of accredited hand surgery fellowships were analyzed for hand surgery cases (2012 to 2013 to 2020 to 2021). The reported case volume was compared by specialty. Temporal trends were described, intrapathway variabilities calculated, and interpathway differences calculated with Student t -tests.

RESULTS

Two hundred plastic surgery (13%) and 1,323 orthopaedic (87%) hand surgery fellows were included. The number of orthopaedic hand surgery fellowships increased from 58 in 2012 to 2013 to 70 in 2020 to 2021 (21% increase), whereas the number of plastic surgery fellowships was stable at 16. Orthopaedic hand surgery fellows reported more hand surgery cases (764 ± 22 versus 628 ± 226), arthroscopy cases (53 ± 54 versus 23 ± 38), and miscellaneous hand surgery cases (42 ± 23 versus 31 ± 18) than plastic surgery hand fellows. Plastic surgery hand fellows reported more cases in wound closure with graft, wound reconstruction with flap, nerve injury, and vascular repair. Overall, orthopaedic surgery offered more experience in 15 case categories (58%), while plastic surgery offered more experience in five case categories (19%). Six case categories (23%) had no difference between specialties.

DISCUSSION

Although orthopaedic hand surgery fellowship affords more cases overall, plastic surgery hand fellowships have unique strengths in wound reconstruction with grafts and flaps, nerve injury, and vascular repair. Ultimately, results from this study create a benchmark to improve future training opportunities for hand surgery fellows and orthopaedic surgery residents.

Residency Training and Hand Surgery Practice Patterns: A National Surgical Quality Improvement Program Database Analysis

Introduction Fellowship-trained hand surgeons may have residency training in either orthopedic, plastic, or general surgery, generating significant variability in education background. To study the effect of different training backgrounds on practice pattern variations, we utilized the NSQIP (National Surgical Quality Improvement Database) database to assess hand surgery volumes and case variety by specialty.

Materials and Methods NSQIP years 2008 to 2017 was queried with hand surgery current procedural terminology codes defined by the American Board of Orthopedic Surgery. Procedures were grouped according to type and specialty, and relative rates calculated. Hand society membership data were used to determine if procedural volume for each specialty in each category and overall contribution to the volume of hand surgery performed nationally was distributed in accordance with membership data.

Results A total of 145,015 hand surgeries were performed; 13,267 (9.1%) by general surgeons, 28,402 (19.6%) by plastic surgeons, and 103,346 (71.3%) by orthopedic surgeons. Orthopedic surgeons performed significantly more bone, fracture, joint, and tendon cases. General surgeons and plastic surgeons performed higher than expected numbers of soft tissue coverage and cases overall with respective excesses of 183 and 22%.

Conclusion Hand surgery is an available fellowship pathway from multiple residencies. Fellowship training does not level the field of real-world practice patterns. Residency training experiences significantly impact practice.

Variability in Hand Surgery Training Among Plastic and Orthopaedic Surgery Residents

Background:

A career in hand surgery in the United States requires a 1-year fellowship after residency training. Different residency specialty programs may vary in case volume. The purpose of this study was to characterize variation in hand surgery training within and between orthopaedic and plastic surgery residents.

Methods:

Publicly available hand surgery case logs for graduating orthopaedic and plastic surgery residents during the 2010 to 2011 to 2018 to 2019 academic years were obtained through the Accreditation Council of Graduate Medical Education. Student t-tests were used to compare mean case volumes among several categories between plastic surgery (PRS) and orthopaedic surgery (OS) residents. Intraspecialty variation was assessed by comparing the 90th and 10th percentiles in each category.

Results:

A total of 6,254 orthopaedic and 1,070 plastic surgery graduating residents were included. The mean hand surgery case volume for orthopaedic residents (OS 247.0) was significantly lower than that for plastic surgery residents (PRS 412.0) (P < 0.0001). Orthopaedic residents performed more trauma cases (OS 133.2, PRS 54.5; P < 0.0001) but fewer nerve repairs (OS 3.3, PRS 28.5 P < 0.0001) and amputations (OS 6.4, PRS 15.8; P < 0.0001). Nerve decompression case volumes were similar between the two specialties (OS 50.2, PRS 47.3; P = 0.34). Case volumes among orthopaedic residents varied considerably in amputations and among plastic surgery residents in replantation/revascularization procedures.

Conclusions:

Orthopaedic surgery residents performed significantly more trauma cases than plastic surgery residents did, but fewer overall cases, nerve repairs, and amputations, while nerve decompression volumes were similar between specialties. This information may help inform residency and fellowship directors regarding areas of potential training deficiency.

Preparation for Hand Surgery Fellowship: A Comparison of Resident Training Pathways

BACKGROUND

Hand surgery is a unique subspecialty in which one can train after completion of either a plastic, orthopedic, or general surgical residency. This study compared hand surgery experience in residency among these different training pathways.

METHODS

The Accreditation Council for Graduate Medical Education case logs of graduating residents in general surgery, orthopedics, and plastic surgery were evaluated for years 2009 through 2018. Cases were grouped according to the Accreditation Council for Graduate Medical Education-defined categories for hand surgery. Comparisons between specialties were made using a one-tail analysis of variance with a 95 percent confidence interval.

RESULTS

There were 19,159 total residents studied: 11,189 general surgery, 7290 orthopedic, and 1040 plastic surgery. General surgery performed the fewest total hand surgeries per individual resident, while plastic surgery performed the most. Plastic surgery performed more operations than orthopedics in all categories studied including tendon, nerve, amputation, soft tissue, fracture, vascular cases, with p < 0.01 for each category.

CONCLUSIONS

There are significant differences in the preparation of resident trainees for entry into a hand surgery fellowship, and the lack of uniform exposure to hand surgery represents an opportunity for improvement. Fellowship directors and the tripartite specialty board should embrace the differences among general surgery, orthopedic, and plastic surgery graduates early in the fellowship year and address the expected differences. Trainees' education should be optimized on an individualized basis with targeted education, additional educational courses, and encouraging trainees to seek out clinical challenges to foster their continued professional growth.

Italian survey on the residents' surgical level in gynecology and obstetrics

PURPOSE

The present study aims to investigate the number of surgical procedures performed by Italian residents and their confidence to carry out different surgeries in obstetrics and gynecology.

METHODS

The present study is a national survey including all Italian gynecology and obstetrics senior residents. A questionnaire including 25 questions was provided. The free Google Forms site was used to create the survey. The study was conducted from April to October 2019. The survey started from the University Hospital of Parma, a tertiary hospital, and was sent to all the Italian post-graduation medical school in gynecology and obstetrics. An e-mail was sent to all representative residents in gynecology and obstetrics in Italy, then forwarded to all the senior residents.

RESULTS

Of the 555 residents enrolled, 100 joined the survey (18.2%). The analysis of the different procedures performed by residents has shown that 53%, 57%, and 77% of the residents had never performed a laparotomic, laparoscopic, and vaginal hysterectomy, respectively. The analysis of cesarean section skills has shown that 1% of residents had never performed any simple cesarean section, and 6% of residents had never performed any complex cesarean section. Fifty-two doctors in training had never performed an operative vaginal delivery. Seventy-three and ninety-three residents performed more than thirty uterine curettages and sutures of 1st or 2nd degree tears, respectively.

CONCLUSIONS

In Italy, senior residents are generally confident with the low-complexity procedures and also with complex cesarean sections. The number of Italian residents confident to perform a hysterectomy is poor.