This symposium is jointly sponsored by the Academic Orthopaedic Society, the American Orthopaedic Association, and the Council on Musculoskeletal Specialties. It gives me great personal pleasure to be able to sponsor a very important topic a little more than one decade after the formal accreditation of the first orthopaedic surgery fellowships. We have a very distinguished panel of participants for the symposium who will address different issues that have arisen or will arise.
My task as the moderator is to describe the evolution and the present status of orthopaedic surgery fellowships. I will discuss the definition, history, present number, distribution, and goals of orthopaedic surgery fellowships. Reginald Cooper and James Urbaniak will discuss the impact of fellowships on orthopaedic surgery residencies, patient care, and orthopaedic practice. John Bergfeld will discuss issues relating to the accreditation and certification of fellowships. James Herndon will talk about the ideal fellowship and the problems and challenges of incorporating fellowships into residencies. James Strickland is going to discuss the private-practice model of sponsoring and funding fellowships. Steven Nestler from the Residency Review Committee will show how other specialties accredit and certify their fellowships. Thus, we have a cadre of leaders who are very experienced in orthopaedic surgery assessing the impact of orthopaedic fellowships on all aspects of the practice of orthopaedic surgery and discussing the future of the fellowships in our specialty.
Merriam-Webster's Collegiate Dictionary defines a fellow as "a person appointed to a position granting a stipend and allowing for advanced study or research."13 The key words here are person and advanced study or research. Interestingly enough, the Accreditation Council for Graduate Medical Education and the Residency Review Committee do not really recognize the word fellow. If one looks closely at the accreditation materials, be they for residencies or fellowships, one finds that the Accreditation Council for Graduate Medical Education uses the word resident and does not use the word fellow. In the 1997—1998 Graduate Medical Education Directory1, the famous green book, the Council defines a resident as "a physician at any level of graduate medical education in a program accredited by the Accreditation Council for Graduate Medical Education. Participants in accredited subspecialty programs are specifically included." Obviously, this latter sentence includes fellows. Later, the authors define fellow as "a term used by some sponsoring institutions and in some specialties to designate participants in subspecialty graduate medical education programs." The 1997—1998 Graduate Medical Education Directory1 and the Accreditation Council for Graduate Medical Education use the word resident to designate "all graduate medical education participants in Accreditation Council for Graduate Medical Education accredited programs." Thus, we can see that there is a lack of formal recognition of the word fellow by the Accreditation Council for Graduate Medical Education.
In order to start the discussion on orthopaedic surgery fellowships, I wrote to some of the individuals who were instrumental in initiating and implementing accreditation of these fellowships by the Accreditation Council for Graduate Medical Education. My understanding from most individuals is that William Donaldson, M.D., not only was instrumental in initiating the first listing of orthopaedic surgery fellowships by the Advisory Council for Orthopaedic Residency Education, but also, most importantly, initiated the concept of accreditation of fellowships through the Accreditation Council for Graduate Medical Education. In addition, there were two relatively unique concepts of accreditation in orthopaedic surgery. First, accredited fellowships without a certification examination were allowed by the Accreditation Council for Graduate Medical Education for orthopaedic surgery fellowships. Almost all other fellowships had and have certification before accreditation. This exemption continues and is often a subject of intense discussion within the Accreditation Council for Graduate Medical Education. Second, under certain conditions, freestanding fellowships are allowed to be accredited without an affiliation with a residency. Finally, most other fellowships are for two or three years and have a major laboratory research component.
I received letters from D. Kay Clawson, M.D., Donald Kettelkamp, M.D., and William Enneking, M.D., about the issues and concerns of the individuals who were responsible for the initiation and implementation of orthopaedic surgery fellowships. All three of them believe that subspecialization will improve patient care. They pointed out potential and real problems associated with the presence of fellows and the effect of this presence on the education of residents. These individuals expressed concerns that general orthopaedists would not be supportive of fellowships and would, in particular, be concerned about malpractice actions. Another area of intense interest was whether all orthopaedic surgery fellowships had to be affiliated with an orthopaedic surgery residency. They uniformly believe that subspecialization continues to improve the level of patient care in many areas of orthopaedic surgery. William Enneking stated that areas of practice in which outcome studies demonstrate clearly superior patient care by subspecialists at a cost that is comparable with that of generalists would continue to flourish. He expressed concern that, if general orthopaedic surgeons had continued conflict with subspecialists, fragmentation of our specialty would ensue, just as happened in general surgery in the mid-part of this century.
Donald Kettelkamp said that accreditation of fellowships was necessary to ensure the quality of the educational program. He and others believe that one cannot decrease the duration of the orthopaedic residency to three years and make the fourth year a fellowship year without jeopardizing the quality of the education of residents. He also went on to say that the accreditation of fellowships and the certification of fellows are necessary to ensure the quality of an orthopaedic education. It was most interesting to me that the letters from these three accomplished individuals identified most of the issues that we will discuss today.
Merriam-Webster's Collegiate Dictionary defines accredit as "recogniz[ing] (an educational institution) as maintaining standards that qualify the graduates for admission to higher or more specialized institutions or for professional practice" and a certificate as "a document certifying that one has fulfilled the requirements of and may practice in a field."13 Thus, just as we attended accredited institutions such as colleges and medical schools, we had to pass a test to get a diploma (certificate). Institutions are accredited by external bodies, whereas individuals receive a certificate.
Likewise, the Accreditation Council for Graduate Medical Education1 defines accreditation as "the process for determining whether an educational program is in substantial compliance with established educational standards," and it considers accreditation to be the responsibility of the Accreditation Council for Graduate Medical Education and its Residency Review Committees. The Council defines certification as "the process for determining whether an individual physician has met the requirements within a particular specialty," and it considers certification to be the responsibility of the member boards of the American Board of Medical Specialties. In our case, this would be the American Board of Orthopaedic Surgery. Thus, the Residency Review Committees determine whether an orthopaedic surgery residency is in compliance with standards, and the American Board of Orthopaedic Surgery is the certifying organization that requires a written test of cognitive knowledge, peer review, and the oral examination of surgical practice to determine whether the individual has met the standards for certification. Thus, one can complete accredited educational programs in a university, medical school, and orthopaedic surgery residency, but no one who does not meet the requirements of the American Board of Orthopaedic Surgery will be certified.
Information on fellowship status was obtained from the 1997—1998 Graduate Medical Education Directory1 by the Accreditation Council for Graduate Medical Education and the listing of the 1997 Postgraduate Orthopaedic Fellowships3 by the American Academy of Orthopaedic Surgeons and the Academic Orthopaedic Society (Table I). Presently, there are eight subspecialty areas of orthopaedic fellowships in the United States and Canada that have been approved by the Accreditation Council for Graduate Medical Education, starting in 1985 with hand surgery and pediatric orthopaedics and most recently including foot and ankle surgery in 1994. The eight subspecialty areas of approved postgraduate orthopaedic fellowships are hand surgery, pediatric orthopaedics, musculoskeletal oncology, sports medicine, adult reconstruction, trauma, spine surgery, and foot and ankle surgery. Of course, the highest percentages of accredited programs are in the fellowships that were initially accredited in 1985 and 1986. In addition, a driving force for the accreditation of fellowships in hand surgery has been the need to have an accredited fellowship to obtain the Certificate of Added Qualifications in hand surgery and to join some of the hand societies.
There are presently 180 programs accredited by the Accreditation Council for Graduate Medical Education, with 331 accredited positions. One must remember that there are more fellowships and fellowship positions than there are programs accredited by the Accreditation Council for Graduate Medical Education. There are 391 accredited and unaccredited postgraduate orthopaedic fellowships outlined in the 1997 edition of the Advisory Council for Orthopaedic Residency Education book3. The number of positions offered and filled in the combined musculoskeletal specialty match from 1993 through 1998 has been relatively stable for the four larger fellowship enterprises14 (Table II). In the last six years, there have been between twenty and twenty-seven fellows matched per year in foot and ankle surgery in the United States. In hand surgery, there have been between eighty-four and 106 fellows matched per year. In pediatric orthopaedics, there have been between eleven and twenty-one fellows matched per year, and in sports medicine there have been between 106 and 125 fellows matched per year. Again, it must be recognized that there are more fellows per year taking these positions than there are in the match. Some fellowships are not in the match, nor are all of the candidates.
To give you a more accurate idea of the magnitude of interest in postgraduate fellowships, the American Board of Orthopaedic Surgery has had a questionnaire for the Part-II (oral) examination for candidates that asks about fellowship experience. These candidates have been in practice for at least two years after completion of the Part-I examination. There are anywhere from 610 to 630 new orthopaedic surgery residency graduates per year in the United States. Because almost everyone (approximately 90 percent of first-time takers) passes Part I and goes on to take Part II, these are probably the most accurate data that we have on the number of individuals taking orthopaedic fellowships. In the 1995, 1996, and 1997 questionnaires, 62 percent, 63 percent, and 64 percent, respectively, of the candidates said that they had taken a fellowship of at least one year. Thus, almost two-thirds of the orthopaedic surgeons who finish an orthopaedic surgery residency take a one-year fellowship. At least from the residents' point of view, there seems to be a need or desire to take an orthopaedic surgery fellowship.
There have been many surveys by the American Academy of Orthopaedic Surgeons and focus groups examining why orthopaedic surgery residents elect to have an extra year of education and training when, except in hand surgery, it does not lead to certification. From the applicants' point of view, there are at least four overlapping reasons to take an orthopaedic surgery fellowship. Some applicants want extra training in an area of interest. Others just believe that they need to have another year's experience to gain confidence and maturity. An especially pertinent reason is that candidates want to be more attractive candidates for job opportunities. They seem to realize that they will no longer practice only their subspecialty, at least initially, but they desire to be able to evolve their practice to a subspecialty. Also, they express the concern of having inadequate residency training in certain areas that they will need in practice situations. The survey of the applicants for the Part-II examination therefore substantiates that the extra year must fulfill a need; otherwise, the number of residents taking fellowships would not be so high. In fact, there is reason to believe that the percentage of newly graduated orthopaedic surgery residents who are taking orthopaedic surgery fellowships is increasing instead of decreasing in spite of public policy to support generalists.
The next six speakers will address whether our orthopaedic fellowships fulfill society's need for advancement of knowledge and technology to improve patient care and whether these fellowships continue to satisfy the orthopaedic surgeon's desire for improved education, training, and research.
Address for Dr. Simon: Section of Orthopaedic Surgery and Rehabilitation Medicine, Department of Surgery, University of Chicago, 5841 South Maryland Avenue, MC 3079, Chicago, Illinois 60637.
I have been involved in a variety of ways in the evolution of fellowships in orthopaedics: as an advocate, as an opponent, as an active participant trying to shape fellowships, and as an observer. I must tell you at the start that I do not claim immutable priority on the answers to questions about fellowships and the related issue of subspecialization. Despite the tendency of governmental agencies and managed care, as currently structured, to reduce the number of subspecialties, we must assume that a certain number of subdisciplines with fellowships will continue. Therefore, we need to be careful in monitoring the continued development of these subspecialties.
Some subspecialization is appropriate for many reasons: (1) the expansion of knowledge and technology; (2) a desire of those with special interests to band together; (3) the perception, and the reality in some situations, that subspecialization provides improved patient care; (4) the development of subspecialty certification; and (5) economic reasons.
Whether subspecialization and fragmentation are inevitably synonymous is a matter of degree. The development of subspecialties and associated fellowships has inevitably induced some fragmentation. Given the extraordinary pressures in health care wherein physicians are losing control of the profession, we must emphasize the common tenets of medicine that bind us together and not reach the stage, described by Archibald in his 1935 address to the American Surgical Association, where "fingers replace brains and handicraft outruns science."4
Before 1984, fellowships in orthopaedics were not accredited. The relatively easy access to finances provided support, and the number of fellowships in all of the orthopaedic subspecialties grew with no perceptible plan or logic. There were no regulations, no quality control, and no assurance of an appropriate educational component related to patient care. Some people noted that this situation might be serious but not hopeless or, on the other hand, that it might be hopeless but not serious. I suggested another alternative: that it might be hopeless and serious. Some specialty societies had developed to an advanced degree, and some had considered developing their own subspecialty accreditation and certification in the early 1980s outside the umbrella of the American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education. By about this time, strained relationships developed between the American Academy of Orthopaedic Surgeons and the American Board of Orthopaedic Surgery. Many members of the orthopaedic community remained opposed to recertification, and they certainly did not want fellowships leading to subspecialty certification, which they perceived as a mechanism wherein regulations might evolve to exclude the treatment of certain conditions from the domain of the general orthopaedist.
Many of us in academic programs recognized the disarray of so-called subspecialty fellowships. We decided that a modicum of order should be injected into this morass in order to establish educational criteria for fellowships. Our Residency Review Committee and representatives from other societies met with the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties to propose accreditation of subspecialty fellowships without subspecialty certification. This was, of course, the reverse of what all other subspecialties except one had done. In 1984, we finally convinced the Accreditation Council for Graduate Medical Education to let us proceed with accreditation in eight subspecialties of orthopaedics on a five-year trial basis. This program was phased in beginning in 1987, with the Residency Review Committee assuming the added task of reviewing fellowships. We now have 180 accredited fellowship programs with 331 positions. The act of instituting accreditation cut the number of fellowships, although some nonaccredited fellowships remain.
The restrictions on finances that were accelerated by the federal government's push for primary care and away from technically oriented and expensive operative subspecialties rendered other institutions unable to afford the $65,000 or $75,000 needed annually for each postgraduate trainee. The recent regulations of the Health Care Financing Administration on billings and audits have also caused many to withdraw their accredited fellowships.
Listing the advantages and disadvantages of fellowships should delineate the impact of fellowships on residency education, patient care, investigation, and practice.
Teaching a limited area, in depth, to residents, and therefore learning by residents, is effective. Fellows certainly relate closely to residents, and they usually fulfill the prime requisite for teaching—namely, availability. The fellows have fewer extraneous commitments than do faculty. If fellows act as early career faculty, as well they should, resident education is enhanced. Fellows are also well positioned to teach medical students and allied health-care workers.
Fellows are able to help with a high volume of patients who have well delineated diseases. They are available to provide day-to-day care and continuity of care. In addition, they enhance emergency care. Fellows show residents the concept of limitations in the care of complex problems that logically demand referral. In practice, patients who have the most complex orthopaedic conditions are best served by a supraspecialist who has additional education and experience, who limits his or her practice, and who maintains a relatively high volume of patients. This may well represent the most cost-effective type of care.
Fellows learn investigate methods, do laboratory research, develop improvements in technology, and engage in clinical research. In these ventures, fellows can be co-investigators with residents and thereby enhance the residents' education.
Fellows serve as a role model for subspecialty group practice. They maintain the number of physicians in academic medicine at a time when academic institutions are under great stress, and they enhance interdepartmental cooperation in teaching conferences and in clinical and laboratory research.
In some instances, fellows have had a negative impact on residency education. They should not be trainees who make up for deficits in their residency education. The Residency Review Committee requirement of having a written agreement that specifies the educational relationship between the residency program and the fellowship program is closely monitored and should be adhered to. Many fellowships have been designed to exploit fellows as so-called slave labor. Fellowships may increase fragmentation if each fellowship does not contain common educational goals that transcend subspecialty boundaries. Fellowships increase the costs of medical education and may eventually lead to increased litigation relating to procedures performed by those without fellowship training. Fellows may be overtrained for some health-care systems that want general orthopaedists, and they may fail to consider the general needs of the patient. Subspecialists may perpetuate the unreasonable exclusion of some physicians from certain privileges, and this may lead to confusion for the patient as to which physicians to seek out for care. Research funding is divided and fragmented among subspecialties, and the literature in the specialty is further fragmented into subspecialty journals.
Some programs have structured two-year fellowships with one year primarily devoted to research for those who want to pursue a career in academic medicine. To me, this seems logical. We also need some subspecialty fellowships for those who want to join a large group practice. If, as we did in Iowa, we establish limited goals for a fellowship—namely, to teach, to carry out an investigative project, and to treat only the complex cases that a faculty member would treat if there were no fellows or the cases that an orthopaedist would not treat unless he or she had education and training in the subspecialty—we probably have too many fellowships. In our subspecialty fellowships, we must continue to guard against so-called intellectual apartheid and functional secession from each other with a further loss of our professional sovereignty.
Address for Dr. Cooper: Department of Orthopaedic Surgery, University of Iowa, 200 Hawkins Drive, Iowa City, Iowa 52242.
I have been privileged to observe orthopaedic fellowships for thirty years since I first supervised a hand fellow in 1969. There is no question in my mind that a well designed fellowship program in hand surgery produces surgeons who are better skilled in operations on the hand and thus are better able to provide optimum patient care. Not only does a well designed and coordinated fellowship program upgrade the subspecialty, but also the intense focus, highly refined expertise, and concentrated knowledge of a subspecialty alone or in combination with other subspecialties strengthen the field of orthopaedics in general.
There are a number of reasons to do a fellowship. A recent survey about hand fellowships was presented by Frederick Duffy at the meeting of the American Association for Hand Surgery in 19988. He surveyed 106 hand fellows who were about to complete their program in 1997, and 75 percent (seventy-nine) responded. Sixty-three percent (fifty) were orthopaedic surgeons, 27 percent (twenty-one) were plastic surgeons, and 10 percent (eight) were general surgeons. When the fellows were asked why they took a fellowship program, the desire to be a better clinician was the overwhelming response. Eighty percent (sixty-three) responded that they took the program because they wanted more training, 33 percent (twenty-six) were concerned about how the absence of a Certificate of Added Qualifications would affect their practice, and 22 percent (seventeen) were concerned about the medicolegal consequences of not having a Certificate of Added Qualifications in surgery of the hand.
All but one fellow believed that their hand fellowship was a positive experience, and all but one believed that they were much better prepared for a career in hand surgery because they had obtained a fellowship. Only 48 percent (thirty-eight) thought that their residency had prepared them for a career in hand surgery. I believe that we would find similar responses if some of the fellows in other subspecialties were surveyed.
The clinician who has had extended clinical training in a subspecialty undoubtedly provides a needed resource for other orthopaedic surgeons who choose to refer rather than to treat patients with complex problems that are better handled by individuals who have specific expertise (for example, patients who need a microvascular operation, a revision total hip arthroplasty, or a complex operation on the spine).
The most important factor influencing the effect of the fellowship on the residency program is the coordinator or the individual in charge of the fellowship or both the residency program and the fellowship program. A properly structured fellowship program that is integrated with the residency program and the fellowship program. A properly structured fellowship program that is integrated with the residency program will only enhance the educational experience of the residents and improve overall patient care. For example, in our program, all fellows who apply are informed that residents come first and fellows, second. When it is appropriate, the resident has the choice of being the first assistant in the operating room and the fellow, the second assistant. Naturally, the complexity of the case, the level of training of the resident, and the experience of the fellow all come into play.
In addition, we do not accept graduates of our residency program into our fellowship program because we believe that it is time for the residents to broaden their learning experience by obtaining their specialized training at another program or institution. In addition, the influx of fellows from various programs exposes our residents and faculty to a greater amount of knowledge and skills. Frequently, at our Grand Rounds, which are attended by faculty, fellows, residents, and students, I ask one of the fellows how a specific clinical situation is managed where he or she was trained.
Because residents usually learn more from their senior residents than from any other teachers, residents at all levels have the opportunity to learn from the fellows. Emphasis is placed on helping the fellows to become better teachers. They are given the responsibility of conducting conferences and giving didactic lectures. Usually, the fellows have more free time than do residents. They can devote more time to reading and research, particularly in areas that focus on their subspecialty, and they often provide valuable teaching assistance to the residents in the operating room. In addition, our advanced residents often teach many of the fellows, which fosters a rich exchange of ideas and techniques.
There are a few disadvantages to having fellowships incorporated into the residency program. For example, when confronted with complex problems of the upper extremity, the residents may say, "Let the hand fellow do it," and the residents may not even show up for the operation if the fellow is involved. Even more importantly, the residents may have less of an interest in studying or learning about some subspecialty areas because the fellows can provide the needed assistance. In addition, because the residents appreciate that there are subspecialists in practice to whom they can refer patients in the future, they may have a tendency to disregard the opportunity to gain knowledge and skills in some areas in which they have less interest (for example, spine surgery or pediatric surgery).
I have personally observed that, in general, our current residents know much less about hand surgery than previous residents did because they do not all attend the Hand Conference; also, the residents frequently rely on the fellows to do some of the teaching in hand surgery and to manage complex cases involving the upper extremity. Many of them, early in their training, seem to concentrate in one or two areas at the expense of knowledge in other fields.
Two levels of patient care are to be considered. Because the fellows obtain more extensive training in a subspecialty, it is apparent that the patients benefit from their increased knowledge and skills. There are, of course, variations in the final product of the trained resident. Indeed, if a resident develops a particular interest in a subspecialty, especially if the program in which he or she trains emphasizes that particular subspecialty and the resident continues to concentrate in that field during the early years of practice, he or she may eventually be as competent as the fellowship-trained subspecialist.
The quality of patient care may not be affected by the presence of a fellow because the attending physician has the ultimate responsibility at all levels of care. However, a capable fellow has the potential to increase the efficiency of the attending physician by enabling him or her to see more patients and, perhaps, to do more operations. A fellow who has worked side by side with an attending physician on a daily basis is particularly helpful when the attending physician is away. The fellow may see some of his or her patients, particularly after operations, and thus provide relief from an overbooked clinical schedule when the clinician returns. The responsible fellow should be well acquainted with the attending physician's patients and his or her treatment protocols, usually more so than a resident, who spends less time on the subspecialty rotation.
I have found that patients are usually quite comfortable with and receptive to a responsible fellow serving as an associate of the attending physician. A skilled and knowledgeable fellow is particularly helpful and can improve the efficiency of patient care particularly in the subspecialties that require a high degree of technical skill. This is especially true when procedures involve operating simultaneously in two different anatomical regions (for example, operations for polytrauma or free-tissue transfers).
In general, because fellows concentrate in only one area, they should participate in basic and outcome research as a part of their training. These assessments may provide useful data that result in improvements or modifications of treatment methods for an overall positive effect on patient care.
Informal surveys of the examinees at the time of the oral examination of the American Board of Orthopaedic Surgery (when the orthopaedists have usually been practicing for at least two years) show that approximately 60 percent of orthopaedic surgeons have had fellowships. Of those who have had fellowships, the number who are practicing solely in their specific subspecialty on a part-time basis far exceeds the number who are practicing in their subspecialty on a full-time basis. I believe that none of us would disagree that subspecialists are not only beneficial but essential in our efforts to maintain the highest standards of orthopaedic care. All of us, regardless of our training, knowledge, and expertise, have at least an occasional need to refer a patient to a subspecialist. As mentioned, an orthopaedic surgeon may become an expert in a specific area or a subspecialist whether or not he or she has had a fellowship. However, supervised training in a well structured program that includes careful supervision, appropriate patient contact, and adequate time for study, research, and an environment that stimulates the fellow to be a teacher should produce more complete subspecialists in a shorter time. The final product is legitimized even more if the fellowship is accredited and especially if it leads to a Certificate of Added Qualifications.
One of the disadvantages of fellowships in the practice of orthopaedic surgery may be the excessive production of subspecialists. Some unnecessary operative procedures may be imposed on patients (for example, unnecessary spinal instrumentation or endoscopy).
Fellowships have the potential both to strengthen an orthopaedic residency training program and to dilute or disrupt it. In the worst case, the fellow serves as the attending clinician's surgical technician. The value of the fellowships to the teaching program depends totally on the guidance of the program director and the attending physicians. The ground rules must be clearly defined for both the fellows and the residents.
The number of faculty members has increased in most medical centers, but the number of residents has remained the same or has become smaller. For example, the number of faculty members at our institution has increased 400 percent in the last quarter of a century but the number of residents has decreased 30 percent. The addition of fellowships in the various subspecialties enables residents to continue to have the appropriate amount of time in the clinics, operating theater, laboratory, library, and conferences. The fellows share the load by assuming many of the responsibilities of the residents, such as assisting in the operating room, assessing patients before they are evaluated by the attending physician, and accepting telephone calls from patients. The entire residency program benefits from the involvement of the fellows.
The funding of fellowships is becoming an increasing problem and perhaps the greatest challenge at most centers. Ideally, the simplest method of funding fellowships is through the hospital. This may be accomplished if the value of the fellowship can be shown to have an impact on the use of the hospital's facilities and services. For example, in subspecialties that involve trauma, it is possible to convince some hospital administrators that the fellows' participation in the treatment of highly specialized types of trauma (such as that necessitating replantation, polytrauma, and that jeopardizing limb survival) enables more patients to be treated in the institution than would be possible otherwise. Billing for fellows' services may be prohibited by the bylaws of some institutions if the fellowship is accredited or leads to a certificate, or both. Grants from the orthopaedic industry and from generous benefactors can be used for funding fellowships if the sources that were mentioned earlier are not available.
In summary, for the past three decades, it has been gratifying for me to witness the rich educational experience for the residents, fellows, and faculty in a well structured program that involves the cooperation of the residents and fellows.
Address for Dr. Urbaniak: Division of Orthopaedics, Duke University Medical Center, Box 2912, Durham, North Carolina 27710.
I was told once by a professional educator that there are problems, concerns, and issues. A problem is something that you can address and for which there is usually a solution. A concern is something that deserves mention but does not have a major effect. An issue is something that, after considerable debate, may remain unresolved. We certainly have problems, concerns, and issues regarding orthopaedic fellowships in the United States. Some of the major issues relate to fellowship directors' knowledge of the process for accreditation and certification, the value of accreditation and certification, confidence in the process of accreditation by the classic Residency Review Committee of the Accreditation Council for Graduate Medical Education, understanding of the financial restrictions on fellows in training, the effect of the Certificate of Added Qualifications on the practicing orthopaedic surgeon, and competition from the Certificate of Added Qualifications in other disciplines.
Two-thirds of our graduating residents are taking fellowships. Fellowships cannot be ignored. In an attempt to get some of the answers to these issues and problems, a survey of the fellowship directors was conducted. Three hundred and ninety-one fellowships are listed in the 1998 combined publication of the American Academy of Orthopaedic Surgeons and the Academic Orthopaedic Society3. The only requirement for being listed is sending in a one-page description of the fellowship. We surveyed the entire group, whether they were accredited or not, and received 157 responses. Thus, our response rate was 40 percent (157 of 391), which I thought was quite good. The survey consisted of eighteen questions and was prepared by me. Those of you who are statisticians may have legitimate criticisms of the survey. Some of the forms were not completely filled out, and respondents did not answer every question. In spite of these deficiencies, I believe that the survey addresses the important problems, concerns, and issues regarding postgraduate orthopaedic fellowships.
The first issue on the survey was fellowship directors' knowledge regarding the established process of certification and accreditation. Approximately 40 percent of the 157 responding fellowship directors gave an accurate description of the process of certification and accreditation, 20 percent were aware of the concepts, and 40 percent were obviously unclear about the process. I asked our orthopaedic sports fellows, who were blinded to the identity of the respondents, to look at the responses. It was their belief that I was being generous by saying that approximately 40 percent of the respondents accurately described the process.
This was disappointing because the introductory page of the survey described exactly how a fellowship program is accredited by the Residency Review Committee of the Accreditation Council for Graduate Medical Education. Still, 40 percent of the respondents either did not read the description or perhaps do not understand what the Residency Review Committee and the Accreditation Council for Graduate Medical Education are. Clearly, our fellowship directors, the leaders with whom we are entrusting the process of accreditation, do not understand the process of certification and accreditation, or at least half of them do not.
Forty-six percent (180) of the 391 orthopaedic surgery fellowship programs are accredited by the Residency Review Committee. This indicates that a lot of work has been done. Hand surgery leads the way, with 91 percent (fifty-three) of the fifty-eight hand programs accredited. In our survey, 54 percent (eighty-four) of the 157 respondents had accredited programs. The Certificate of Added Qualifications in hand surgery is a major factor in accreditation. Each of the different subspecialty groups has a different attitude toward accreditation.
When the fellowship directors were asked on the survey whether they thought that accreditation has value, 78 percent (107 of 137) said "yes." Sixty-one percent (eight-four of 138) said that their program was accredited. Ninety-two percent (eighty-two) of the eighty-nine who had accredited programs planned to continue accreditation. Thirty-one percent (fifteen) of the forty-eight whose programs were not accredited said that they would apply for accreditation if it were available in their specialty, but many of the respondents replied that accreditation was not available. Interestingly, there were some who stated that they would not apply for accreditation even if it were available. When asked whether accreditation affected the attractiveness of their program, 54 percent (forty-four of eighty-one) responded that it made the program attractive to the applicants, 21 percent (seventeen of eighty-one) responded that it hindered the program, 16 percent (thirteen of eighty-one) wrote that the question was not applicable.
Some of the comments were of value: "accreditation is too cumbersome and too bureaucratic," "the variations in the programs make it impossible to do an overall or general accreditation" (this was particularly true in spine surgery), "too much paperwork," and "the accrediting body has no guts to close a poor program." The positive comments included the following: "it makes a program director develop a curriculum" and "it stops apprenticeships and ensures a quality program."
Next, the directors were asked who should carry out the accrediting process. Only 52 percent (sixty-seven of 128) said that the Residency Review Committee should give the accreditation; 39 percent (fifty of the 128) said that the specialty societies should do so, 6 percent (eight of 128) said that the American Board of Orthopaedic Surgery should do so, and 2 percent (three of 128) said that others should do so. The variation in the responses reveals concerns about the level of confidence in the accreditation process of the Residency Review Committee. As mentioned earlier, some groups are doing their own certification and accreditation. For example, the Arthroscopy Association of North America has its own fellowship in arthroscopy and provides an accreditation process. The Council of Spine Surgeons has come together for the purpose of improving its fellowship program, and there is a new, self-designated American Board of Spine Surgery. Clearly, there are people going out on their own to circumvent or to supplement the classic process of accreditation and certification by the Residency Review Committee of the Accreditation Council for Graduate Medical Education and by the American Board of Orthopaedic Surgery of the American Board of Medical Specialties.
The next issue on the survey was that of certification. When asked whether certification or giving a Certificate of Added Qualifications has added value, 60 percent (seventy-three) of the 122 respondents said "yes." If certification were available, 69 percent (eighty-eight) of the 127 respondents would encourage their fellows to pursue it and fifteen of nineteen hand surgeons who now have the Certificate of Added Qualifications would do so. One director of an accredited fellowship program said that he did not encourage people to take the Certificate of Added Qualifications, but when we read all of his responses it became obvious that this person was against just about everything. He went on about how we as orthopaedic surgeons had orchestrated the "unnecessary certification process." He blamed orthopaedics for all of the bad things about certification, saying that "it is a marketing tool only." He also believed that "the grandfather clause is inappropriate" and that "this is a danger to our profession, but it is good for the public." I thought that this response was worth mentioning.
Another question was whether the fellowship directors believed that the Certificate of Added Qualifications in hand surgery affected orthopaedic practice. Sixty-three percent (thirty-five of fifty-six) said that it had no effect, 30 percent (seventeen of fifty-six) said that it was a hindrance, and 7 percent (four of fifty-six said that it helped. The following responses were of interest: "the public is unaware of the Certificate of Added Qualifications and could not care less" (a response that was repeated several times), "it is discriminates against those who do not have the Certificate of Added Qualifications," "the fellows want it," and "the Certificate of Added Qualifications is a threat to practicing orthopaedic surgeons." As evidence of this last response, a resolution of the American Academy of Orthopaedic Surgeons that was reinstituted in 1995 states: "It shall be the policy of the American Academy of Orthopaedic Surgeons to oppose the issuance of any additional Certificate of Added Qualifications in orthopaedics." It speaks for itself as to what the rank and file think about the Certificate of Added Qualifications.
Like hand surgery, primary-care sports medicine has a unique situation. In that subspecialty, there is a Certificate of Added Qualifications, obtained through the classic procedure. Four American Board of Medical Specialties members—the American Board of Family Practice, the American Board of Internal Medicine, the American Board of Pediatrics, and the American Board of Emergency Medicine—obtained their Certificate of Added Qualifications. At present, their respective Residency Review Committees are in the process of accrediting their fellowships. These directors of primary-care fellowships share a concern about an additional Certificate of Added Qualifications in another discipline, such as orthopaedic surgery.
Many responses echoed concern about the special issues facing orthopaedic sports medicine: "we feel that there is competition for appointment to team-physician positions, especially in universities and other places that look at things like accreditation and certification," "there is competition for the nonoperative sports injuries," "there is competition for the health maintenance organization contracts," "there is a threat of being labeled as a `technocrat'," "you're only a surgeon because, look, I have passed my Certificate of Added Qualifications in sports medicine, which covers more than just the operating room," and "orthopaedists are unable to take the Certificate of Added Qualifications."
To sit for the Certificate of Added Qualifications in sports medicine, one must be a diplomate of one of the specialties represented by the four aforementioned boards. Therefore, almost every orthopaedic surgeon is ineligible.
Seventy-eight percent (101) of the 129 fellowships are directly associated with a residency program. One of the criteria for accreditation of a fellowship program is association with a residency program. Not all fellowships have such an association. The survey asked: "What are your feelings about how the fellowship affected your residency program?" Twenty-one percent (twenty-eight) of the 136 respondents said that it had no effect, 10 percent (thirteen of 128) said that it was a hindrance, and 70 percent (ninety-five of 136) said that it helped. Many of the responses of the fellowship directors were that "the fellow can teach the first or second-year residents" and "the entry-level resident is taught very well by the fellow." The directors who believed that the fellowship hindered their residency program uniformly attributed the problem to competition between the fellow and the senior resident for surgical cases. Far and away, however, most fellowship directors believed that the fellowship program helped from the residency program.
When asked whether the present changes in medicine affected the number of fellowship applicants, 51 percent (fifty-seven of 112) said "yes," 40 percent (forty-five of 112) said "no," and 9 percent (ten of 112) were undecided. Most of the responses were that there are too many orthopaedic surgeons already and that the fellows are not helping any.
A financial restraint was perceived regarding accreditation. Fellows in an accredited program associated with a university are reimbursed at graduate level 6 through the Health Care Financing Administration program. The perception of a financial restraint may be based on the belief that the Health Care Financing Administration may be reducing reimbursement for graduate levels 3 through 6 in the future. Fifty-one percent (fifty-six) of the 109 programs were reimbursed by the Health Care Financing Administration, and 49 percent (fifty-three) were not. In 39 percent (forty-eight) of the 122 programs the fellows charged for services within the scope of their program, and in 61 percent (seventy-four) they did not. In 78 percent (ninety-nine) of the 127 programs the fellows charged for services outside the scope of their program, and in 22 percent (twenty-eight) they did not. When asked whether the fellows charged for services in or outside of the scope of the training program, 54 percent (sixty-five) of the 120 directors said that they did not.
We asked for the directors' interpretation of the rules of the Health Care Financing Administration. The respondents were given three choices and were asked to pick the ones that they believed were appropriate. Eighteen percent (twenty-two of 120) believed that they could charge for patients who were not covered by Medicare for services within the scope of the training program; 13 percent (fifteen of 115) believed that they could charge for services outside the scope of the training program, whether or not the patients were covered by Medicare; and 13 percent (fifteen of 115) believed that they could charge for all patients who were not covered by Medicare for services outside the scope of the training program.
These responses regarding financial issues may seem confusing, and they may well be. I asked the graduate education directors of two major multidisciplinary teaching facilities in the United States what their policy was regarding fellows charging for services. One director said that it is the general policy of the institution that fellows not charge for anything. The second director said that the policy of the institution was that fellows do charge for selected services. When asked the reason for these differing policies, the answer was that they were simply following their lawyers' interpretation of the rules of the Health Care Financing Administration. Thus, the lawyers for the two institutions interpreted the rules in different ways. There was even some concern expressed regarding the fact that the lawyers within each institution did not agree with each other. With this in mind, I am sure that the fellowship directors' interpretations would be quite varied and confusing, and understandably so.
The next survey question asked fellowship directors whether they would drop the accreditation of their program if it substantially reduced the fellows' ability to charge for services. Thirty-nine percent (forty-eight of 122) said "yes," 61 percent (seventy-four of 122) said "no." A similar question was posed when they were asked whether, given the present circumstances, they would still seek accreditation if one of the accreditation criteria was that the fellows were not permitted to charge for any services. Sixty-three percent (fifty-seven of ninety) said "yes," and 37 percent (thirty-three of ninety) said "no." Thus, more than 60 percent of the fellowship directors would continue accreditation whether or not they were allowed to charge for fellows' services.
This survey brings to light many issues worthy of debate concerning the certification of fellows and the accreditation of programs. Resolution will be difficult. Still, several problems can be solved, such as the lack of fellowship directors' knowledge about the process for accreditation and certification. Many of the concerns that were expressed are worthy of mention but should not be an obstruction to the overall goal of the improvement of orthopaedic education.
The purpose of this debate and our survey is to bring to light the problems, concerns, and issues, not to resolve them. Hopefully, this will provide a basis for resolution of at least some of these problems, concerns, and issues in the future.
Address for Dr. Bergfeld: Section of Sports Medicine, Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-41, Cleveland, Ohio 44195. E-mail: bergfej@cesmtp.ccf.org.
Donald G. Langsley, M.D., stated, "The advances in medical science and technology have so greatly expanded many specialties that diplomates have limited their practice."12 Dr. Langsley was referring to fellowships in all fields of medicine. I think that his statement is particularly applicable to orthopaedic surgery. There has been growth in the number of fellowships in orthopaedic surgery during the last fifteen to twenty years. One obvious goal of such subspecialty training is to produce experts who can become clinical, research, and educational leaders in the subspecialty. In general, fellowships have matured into one-year experiences, either as preceptor-type training or in an environment with a core of faculty, educational goals and objectives, and a research requirement. Rarely, this latter type of fellowship extends for two years.
Fellowships obviously add one or two years of training to an already lengthy educational process. Currently, five years of residency training are fully funded by Medicare, with some contributions from other third-party payers. However, this funding is shrinking. Not only is the number of residents for whom funding is provided probably going to diminish, but the indirect payments and disproportionate share to hospitals are being reduced. Further reductions are planned, and there is speculation that funding will not be provided for residents and fellows who have completed the time required for initial certification (a maximum of five years). This, coupled with the fact that the average indebtedness of medical students is approximately $70,000 (as much as $150,000 in some cases), leads me to believe that we should be developing methods to reduce the duration of training. Young physicians will not be able to resolve this indebtedness in the future as revenue declines. Fellowship directors will find it difficult, if not impossible, to pay stipends to fellows; hospitals will not pay such stipends; and Medicare and managed care may eliminate the possibility that the fellows can bill for their own services, except in unique situations. In this brief paper, I focus on two issues: (1) moving the subspecialty fellowships into the residency curriculum and (2) the ideal academic fellowship. For the first issue, I discuss the problems, challenges, and funding; for the second, the duration of training, the laboratory component, accreditation, the process of receiving a Certificate of Added Qualifications, and funding.
Medical education and postgraduate training are too long. Medical students today carry a large load of debt upon graduation. This debt is a tremendous problem and will probably worsen in the future. With physicians' revenues declining, an oversupply of physicians, and restraint of care in the managed-care market, margins from clinical income will become so narrow that it may be impossible to pay off this debt without undue sacrifice. Additionally, there have been recent reports that the specialty choice of medical students is determined by potential future income.
The federal government currently pays for residents through the fifth postgraduate year with a one-half-full-time equivalency payment for the sixth postgraduate year and thereafter. In the future, this funding base will probably stop after the fifth postgraduate year, with Medicare providing support for only five years of postgraduate training or until the first initial certification is obtained. Other third-party payers that will contribute to medical education no doubt will follow Medicare's lead. In addition, the indirect payment is decreasing yearly and the floor for such payment is yet to be determined, but many people in Washington want it to disappear.
Many orthopaedic subspecialty fellowships are supported by the practice income of the program director or the clinical revenue generated by the fellows. Again, as revenues fall and margins decline, it will be impossible for the fellowship directors to continue the present level of support, which includes not only fringe benefits but also malpractice insurance. With the recent changes in Medicare and the problems of accreditation and payment for fellows' services, it will be unlikely that the fellows in accredited programs, except in unusual circumstances or defined situations, will be able to bill for their services. For these financial reasons, I believe that many of our fellowship subspecialty programs should be in the fifth postgraduate year of training. Five years of training is a long time. Many orthopaedic surgeons' practices consist of general orthopaedics with a focus in one or two major areas. We should be able to train a general orthopaedist and a foot surgeon, a general orthopaedist and a sports medicine specialist, or a general orthopaedist and a spine surgeon in a five-year block of time. If we were able to accomplish this change, the funding of fellowships would no longer be an issue. The financial burden would be removed from the hospitals, the fellowship program directors, and the fellows.
Movement of the fellowships into the residency programs cannot occur if there is a subspecialty certifying examination such as the Certificate of Added Qualifications or the Certificate of Special Qualifications. The requirement for such an examination is that, after initial certification, the candidates complete an additional year of training in a fellowship program approved by the Accreditation Council for Graduate Medical Education. The candidates must be certified in their primary specialty before taking this examination17. Currently, in orthopaedic surgery only the subspecialized field of hand surgery has a Certificate of Added Qualifications-approved examination with required Accreditation Council for Graduate Medical Education-approved fellowships16.
The problems with such a radical change, however, include the fact that many residencies lack enough patient volume and faculty as well as research in a subspecialized area to allow for a specific type of training. Residents in such programs who desired a particular experience that was not available obviously either would not have the desired experience and would finish a general program or would have to seek training elsewhere after completing their residency. Residency program directors could organize a system that allowed residents to switch programs in their fifth year in an attempt to provide the desired subspecialty experience. Even though such resident switches would be complex, it would be possible to organize them.
Additional problems include an interference with the residents' training in programs that have a low volume of patients, an obvious change in the relationship that exists today between the fellow and the fellowship director, and a decrease in the overall workforce in the combined residency and fellowship programs because of the lack of the additional layer of post-residency fellows2. Also, in some cases, there might not be sufficient time in the training program for individuals to mature enough clinically as physicians and surgeons.
The challenges involved in the implementation of such a proposal include the elimination of the desire by some to add the Certificate of Added Qualifications process and to obtain such a certificate to be competitive in the marketplace. The approval process of the Residency Review Committee would need to include acceptance of combined residency and fellowship programs that have subspecialty and generalist training. There would need to be close monitoring of the clinical and operative experiences of the residents, with concurrent subspecialty training; this monitoring is currently done by the Residency Review Committee as it reviews the effect of fellowship programs on resident training. An additional challenge would be to not allow service issues to take precedence over educational requirements while allowing some residents in their fifth postgraduate year to move between programs for subspecialty training.
The American Board of Orthopaedic Surgery already has a precedent for awarding certificates in orthopaedic surgery with a subspecialty designation, and therefore certification and recertification are not issues for such individualized programs and their graduates. Finally, for further improvement in the musculoskeletal background of individuals planning careers in various fields dealing with musculoskeletal problems, it would be important to plan with our medical school deans a restructured fourth-year medical-school curriculum to include basics in anatomy, mechanics, physical modalities of treatment, pathophysiology of musculoskeletal disease, and biology of connective-tissue disease. Such a year would provide a solid foundation for many different musculospecialty caregivers as well as orthopaedic surgeons.
The specific background of individuals—that is, whether or not they have subspecialized in a clinical area of orthopaedic surgery—would determine the duration of the ideal academic fellowship. A suggestion is two years, with an emphasis on research, or occasionally even three years, with completion of an advanced degree. This fellowship should include a major research component, either in the laboratory (molecular biology or bioengineering, for example) or in the clinical area with an emphasis on clinical trials, population-based studies, outcomes research, and multi-institutional studies. Advanced degrees would include a master's degree, such as a Master of Public Health or possibly a Master of Business Administration, or a doctoral degree.
Some would argue that accreditation would not be necessary, but I think accreditation stresses the importance of maintaining a minimum standard of excellence, requires a focused definition of educational and research requirements, and emphasizes the responsibilities of the director of the fellowship or residency program, or both. Whether a Certificate of Added Qualifications is necessary is questionable. An argument for a Certificate of Added Qualifications is that it serves a basic educational principle: a student is examined on material that must be learned and substantiates that the required body of knowledge or the operative skills, or both, have been learned. Also, many desire certificates in recognition of their achievements5. Arguments against the Certificate of Added Qualifications are that it may fragment orthopaedics, that it allows for market discrimination and for advantages that are not deserved, and that there is a potential risk of increased exposure to malpractice actions for those without such certificates.
The problem with funding such an ideal academic fellowship is that there is no one to pay for it. There are possible solutions to the funding problem as it becomes increasingly obvious that clinical income cannot continue to support fellowships to the extent that it has in the past. These solutions include training grants (which are rare in orthopaedic surgery), research grants, and, most importantly, endowments. Institutions, departments, and individuals will have to raise endowment money to continue to fund their educational and research missions, including fellowship training. Endowed chairs and educational endowments for postgraduate training will ensure continued commitment to the growth, productivity, and development of our specialties and subspecialties.
There are basically five types of fellowship programs:
1. Programs in which all subspecialty training is included in the fifth postgraduate year of residency training and does not lead to a Certificate of Added Qualifications. A major requisite that this subspecialized training cannot interfere with the residency program.
2. Programs that have approved Certificate of Added Qualifications or Certificate of Special Qualifications examinations. In these subspecialties, at least one additional year in an accredited program is required after completion of the primary residency program with initial board certification. Currently, only hand surgery has such a fellowship program and Certificate of Added Qualifications examination.
3. Preceptorships, with the duration of training variable (usually six or twelve months). These types of fellowships will continue because some individuals will want subspecialty training experience that they did not obtain during their residency9. One-year fellowships in this category are the common kinds of fellowships that exist today, especially in the fields of pediatric orthopaedics, spine surgery, joint replacement, and sports medicine. Additionally, some people will always want to differentiate themselves within the marketplace, and take additional training in order to do so, and hope to achieve a desired position somewhere with a subspecialty background. There will always be these types of fellowships, probably of shorter duration than a year in many cases as the finances become more difficult.
4. One-year fellowships in which the fellow spends time in a program at a center of excellence in a subspecialty. There are usually two or more faculty members who are working in the subspecialty and are developing new technologies, describing new techniques or new treatments, and doing innovative clinical or basic research7. This type of fellowship also exists today, but I think that it could be included in the fifth year of the orthopaedic residency training.
5. Two-year (or possibly three-year) fellowships with a major research commitment. The fellow learns the scientific method, hypothesis testing, and appropriate techniques in the laboratory or appropriate skills for clinical research (understanding how to design and complete randomized clinical trials, prospective studies, outcomes research, population-based studies, and multi-institutional studies within their integrated delivery system or among academic medical centers, or both). Graduate training would allow these individuals to pursue advanced degrees at the master's or doctoral level, possibly a Master of Public Health in epidemiology and statistics or a Master of Business Administration for those who strive for leadership positions in management. This last type of fellowship would be the foundation from which our future health-care leaders would arise.
It is important that orthopaedic surgery not lose its participation in basic research in bioengineering and, most importantly, in biology and the molecular-genetic basis for disease, injury, and repair of connective tissues. We must continue to maintain an intact bridge between the tremendous advances in science and technology and the operative and nonoperative management of musculoskeletal problems.
Address for Dr. Herndon: Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Gray 624, Boston, Massachusetts 02114. E-mail address for Dr. Herndon: jherndon@partners.org.
This discussion should begin with one basic premise: the overall objective of fellowship training in orthopaedic subspecialties is, above all else, to provide the absolutely best educational experience for those who have devoted a year of their lives to improving their knowledge base and technical skills in that discipline. The setting for that training is immaterial as long as the program can provide the essential components of quality instruction that is not restricted by political, institutional, or financial policies or constraints.
When one analyzes the ability of academic centers and private practices to provide fellowship training in orthopaedic subspecialties, it is necessary first to determine the ingredients of good post-residency training and then to compare how each setting can best provide that education. It is important to recognize that, in the face of explosive changes in the health-care delivery system, the fellowship experience can best serve the trainees by going well beyond the time-honored emphasis on the delivery of specialized musculoskeletal care and providing exposure to the practice organization and management skills that will contribute to their success when they enter a practice.
A good post-residency fellowship in an orthopaedic subspecialty must begin with a teaching staff that is uniformly committed to providing high-quality training and is willing to contribute its time and expertise freely for both formal and informal instruction. The program must be carefully configured to meet the educational needs of the fellows rather than simply to serve the logistical needs of the practice or department. It must provide balanced rotations of the fellows among staff with varied interests so that there is adequate exposure to the management of a wide variety of conditions within a subspecialty. The program must also be designed with sufficient flexibility to allow all fellows to participate in difficult or rare cases or those that they deem necessary to fill deficiencies in their knowledge base.
Whether institutionally or privately based, a strong fellowship experience must include scheduled teaching sessions that are both informal and didactic. Lectures should be structured to provide in-depth and comprehensive coverage of the entire spectrum of the subspecialty and should include generous time for discussion. Library services and online computer-database acquisition capabilities are also critical to the fellows' ability to supplement their knowledge base, prepare for cases, and conduct research. There should also be a well equipped laboratory available for anatomical dissection, development of skills, and at least simple research projects. In addition, facilities, time, and resources should be allocated for instruction and hands-on training in special skills unique to the subspecialty, such as arthroscopy or microsurgery.
Aside from the need to provide concentrated and comprehensive training in the diagnostic, nonoperative, operative, and postoperative management required in a particular orthopaedic subspecialty, it now seems apparent that the fellowship training period provides the perfect opportunity to educate the young surgeon in the nuances of practice administration. Most residency programs provide little or no instruction in this difficult area. An appreciation of the methods required for providing the most cost-effective, quality-preserving patient care should be instilled in the young surgeon. Practices designed to attain and maintain patient access are also important skills that the fellow needs in order to successfully enter today's practice environment. The practice-management component of the fellowship curriculum should include presentations on practice administration, medical ethics, record-keeping, billing, coding, patient flow, patient education, scheduling, personnel management, ancillary services, cost control, marketing, reporting, data systems, physician profiling, Workers' Compensation, outcome generation, patient satisfaction, medicolegal issues, managed care, malpractice, contracts, sexual harassment, and capitation.
The fellowship program should also provide consultation that will aid the fellow in making decisions with regard to entering private practice. Discussions of the pros and cons of different practice opportunities and instruction on the basic mechanics of developing employment contracts are very valuable.
Currently, fellowship training is provided in academic centers and in private general or subspecialty orthopaedic practices. Although there are obvious differences in staff composition, funding sources, and overall service responsibilities, both types of programs should share the goal of providing the highest-quality educational experience for the fellows in training. There are a number of factors that may affect the quality of training and, whereas many are unique to the particular academic institution or private practice, others are dictated by incentives and responsibilities of the teaching staff and by their economic motivation.
Academic centers are usually encumbered by teaching staffs that have a broad spectrum of responsibilities, including patient care as well as formal and informal instruction of medical students, interns, residents, and fellows. In addition, almost all medical-center faculties have some obligation to conduct basic research and to involve themselves in various departmental and institutional activities. Most orthopaedic departments have a primary commitment to training residents, and the fellowship experience may be subjugated to that need.
Private-practice fellowship programs, and particularly those that are devoted entirely to a single orthopaedic subspecialty, may be much better prepared to concentrate their entire academic effort on fellowship training. Because they are not hindered by institutional rules or policies, private-practice fellowships permit the creation of educational programs that have a strong emphasis on operative skills, flexible and relevant didactic teaching, and an atmosphere designed to foster the development of practical and timely clinical reasoning and decision-making. Unfortunately, this flexibility can be abused, and private practices need to make a strong effort to see that policies are in place to govern fellowships because no uniform postgraduate structure may exist.
There are certain practical aspects of a private-practice fellowship that can help to prepare the young surgeon to begin a private practice. For example, a private-practice fellowship might be able to provide a broader and more diverse clinical experience resulting from a volume-oriented practice structure and a wider spectrum of patient referrals. Fellows in this setting benefit from frequent exposure to common conditions that are less likely to been seen in academic centers.
Private subspecialty practices offer an excellent opportunity for the development and refinement of components of the important doctor-patient relationship, or bedside manner, that is often difficult to foster in a medical center or general hospital environment, where the ability to evaluate, operate on, and follow the same patient is hindered by conflicting clinical and surgical scheduling and emergency procedures. Learning to gain the confidence of patients through careful examination and meaningful explanation of conditions and treatment, as well as acquiring the disposition to deal honestly and appropriately with complications and patient dissatisfaction, are integral to private practice and prepare the fellow to be a caring doctor in his or her community. Moreover, private-practice fellowships, because of their more focused structure, can better establish the importance of a cooperative team approach among all physicians and between physicians and nurses, therapists, and support staff.
Private-practice fellowships also engender an understanding of the importance of immediate availability for consultation and rapid response and an appreciation for the need to practice cost-efficient medicine. The need to establish strong relationships among referring physicians, emergency room physicians, and other referral sources may also receive more emphasis in a private setting, and the opportunity to learn practice-management skills may be best provided by a small private organization in which administrative decisions are, for the most part, the responsibility of the orthopaedic physician partners.
This is a quote from one of this year's fellows at the Indiana Hand Center: "We all come from residencies in large medical centers and are very familiar with ivory tower medicine and city or county hospital medicine. Private medicine is completely different, and the exposure gained during a private practice fellowship is invaluable."15
It should also be noted that the quality of patient care in private practices will improve as a result of the participation of well trained specialty physicians. This added manpower may free up the staff physician to spend more time with patients who have difficult problems and to provide informal, one-on-one instruction to the fellows.
It is probably best for all fellowship programs, whether academic or private, to be formally aligned with a residency training program and, as a result, to be subject to review by the Residency Review Committee. This accreditation process holds the program accountable for establishing educational standards and, it is hoped, prevents the establishment of fellowships purely to increase manpower and practice income. Although there may be some increased costs for the program to qualify for and achieve accreditation, these costs should not be prohibitive.
The source of funding for academic fellowships in orthopaedic subspecialties has historically been from the departmental budget lines, which include direct and indirect government funding from Medicare Part A. Private-practice fellowships, on the other hand, have received funding from a variety of sources, including hospitals, clinics, private educational foundations, individual physicians, or practice revenue. If the practice is to support the fellows directly, then it may consider generating revenue by billing for the fellows' services to offset their salaries and expenses.
It should be recognized that practices, clinics, and hospitals may bill private insurers for reasonable fees for any services provided by the fellows whom they employ. The attitude toward reimbursement for fellows' services varies among insurers; however, unless a policy states otherwise, the insurers can be held legally responsible for reimbursement. Remember that the fellows are Board-eligible orthopaedic surgeons and that insurers are already paying for services rendered by physicians who have not entered into fellowships.
The most controversial issue regarding reimbursement for the services of fellows is a result of the difficulty of interpreting the Medicare and Medicaid rules. It is remarkable how many fellowship directors and administrators of medical education departments do not know or understand the rules or are influenced by untested interpretations of those rules by self-serving organizations.
All fellowship administrators should be guided by the following.
1. "Medicare's Final Rule for Teaching Physicians" (section 2020.8)10 and "Supervising Physicians in Teaching Settings" (section 15016)11 of the Health Care Financing Administration's Medicare Part B Carrier Manual, which was published on December 8, 1995, and became effective on July 1, 1996. These rules replaced IL-372. Specifically, section 2020.8B provides guidelines with regard to the reimbursement for residents' (fellows') services for Medicare recipients.
2. The Code of Federal Regulations, title 42, volume 2, parts 400 to 429, which was revised on October 1, 19976. Specifically, sections 413.85 and 413.86 of this document address the matter.
3. Interpretations of these rules by other agencies, such as the Bureau of Policy Development of the Association of American Medical Colleges, are worthy of study but must be viewed as untested legal opinions.
Before these rules are analyzed, some general information with regard to Medicare and Medicaid is appropriate:
The Medicare program makes two explicit payments to teaching hospitals for a portion of the added costs associated with operating educational programs in health professions. These payments are the Direct Graduate Medical Education and Indirect Medical Education payments.
The Medicare Direct Graduate Medical Education payment compensates teaching hospitals for some of the direct costs related to the graduate training of physicians. The added direct costs include: (1) stipends and fringe benefits for residents, (2) salaries and fringe benefits for faculty who supervise the residents, (3) other direct costs and allocated institutional overhead costs such as maintenance and electricity, and (4) the costs of clerical personnel who work exclusively in the Graduate Medical Education administrative office. For Direct Graduate Medical Education, Medicare pays each hospital a portion of its unique per-resident amount, which is based on the Direct Graduate Medical Education costs incurred by the hospital during a base-year period.
The Indirect Medical Education carries a medical education label, but its purpose is much broader. It actually is only a proxy to account for a number of factors that may legitimately increase costs in teaching hospitals.
The Health Care Financing Administration has decided that there is no difference between a resident and a fellow. Anything that involves training is considered to be covered under Medicare Part A. Any reimbursement to fellows under Medicare Part B is believed to be so-called double-dipping, even if fellows receive no reimbursement from Medicare Part A.
Most available documents on reimbursement for Medicare services are indicative of the general rule and custom that graduate medical education is hospital-oriented, and thus there is an established methodology for payment for the support of the program. Typically, the hospital provider is paid by Medicare on the basis of the hospital per-resident amount and on the graduate medical education cost incurred by the hospital during a base year (as indexed). Physicians, interns, residents, and fellows working in this environment are not permitted to bill hospital patients separately for their professional services. The sole reimbursement is to occur through payment by Medicare to the provider.
Section 2020.8B10, "Interns and Residents," of the Medicare Part B Carrier Manual provides the following.
Medical and surgical services furnished by interns and residents (and fellows) within the scope of their training program are covered as provider services effective with services furnished on or after July 1, 1987, this includes services furnished in a setting which is not part of the provider where a hospital has agreed to incur all or substantially all of the costs of training in the non-provider facility. The Medicare intermediary is required to notify you of all such agreements. Where the provider does not incur all or substantially all of the training costs and the services are performed by a licensed physician, the services are payable on a reasonable charge basis by the carrier.
Regulation 413.86(f)(1)(iii) of the Code of Federal Regulations, title 42, volume 2, parts 400 to 429 (revised October 1, 1997)6 provides instruction for limiting the number of full-time-equivalent residents in determining a hospital's resident count. This section pertains to residents who spend time in nonprovider settings, such as freestanding clinics, nursing homes, and physician's offices. Unless the outside entity and the hospital have a written agreement stating that the residents' compensation for training time spent outside the hospital setting is to be paid by the hospital, then the resident must be excluded from the resident count of the hospital.
Interpretation of these rules varies considerably. Private-practice orthopaedic fellowship programs whose fellows receive all or part of their salary from a teaching hospital that receives direct funding from Medicare Part A may not, in any way, bill for the services of the fellows in training in that program. However, when the private-practice fellowship absorbs all or substantially all of the training costs for its fellows, when those fellows are not included in a hospital's count of full time-equivalent residents, and when the services of the fellows are provided entirely or almost entirely at an outside entity with which the hospital does not have a written agreement, the practice may bill for the services of the fellows.
There are, however, confusing interpretations of these rules that extend their meaning (and perhaps their intent) and create some concern. The following are several excerpts from a letter, dated February 24, 1997, to all associate regional administrators of the Division of Medicare from Barbara O. Wynn, the Acting Director of the Bureau of Policy Development at the Association of American Medical Colleges18.
Hospitals do not have to incur costs for residents, fellows, etc., to count them for Graduate Medical Education, and the main consideration is whether the individual is in an approved program and, therefore, eligible to be included in the hospital's direct Graduate Medical Education count. The argument that such residents should be able to bill for their services as physician services because the hospital does not pay their salaries is immaterial because the law clearly establishes Direct Graduate Medical Education as the payment mechanism for services furnished in a hospital by individuals in an approved residency (fellowship) training program that leads to certification in a specialty or subspecialty.
Under the law, costs associated with the services of the resident in an approved program in a hospital are payable as hospital services. It does not make any difference whether or not the hospital incurs compensation costs for the services of the resident. The hospital is entitled to receive Direct Graduate Medical Education payments for the time the resident or fellow spends working in the hospital (including all inpatient and outpatient settings that are part of the hospital).
If there is no such agreement under which the time in non-provider setting is included in the Direct Graduate Medical Education count and the resident or fellow is fully licensed, the resident or fellow's services in the nonprovider setting may be covered and billable as physicians' services. The claims may be billed by the fellow or reassigned to the fellow's employer. Thus, there is more flexibility regarding the way the services of a fellow are paid outside the hospital setting.
To conclude the discussion of the reimbursement rules issue, it should also be noted that the services of individuals designated as fellows who are not in any formally organized training program and who are fully licensed to practice are to be paid for as physicians' services. Payment for fellows in these unlisted programs cannot be made under the Direct Graduate Medical Education payment mechanism because the programs do not meet the definition of an approved program in section 413.86(b).
Although there is room for concern with regard to the exact status of private-practice fellowship programs under current federal regulations, it would appear that services provided by fellows in private-practice programs are billable when they are provided in the setting of a nonteaching hospital that has no contractual relationship with that hospital and the fellow is not included in the Graduate Medical Education count of the hospital. Legal advisors to our own practice have investigated this issue exhaustively, and they strongly believe that a private-practice fellowship that receives no outside funding for its educational programs and provides the majority of its services outside any institution that receives Medicare Part-A payments for medical education may bill for the services of its fellows, even when that program is accredited by the Accreditation Council for Graduate Medical Education.
To bill Medicare and Medicaid for fellows' services, the fellowship program should (1) avoid any funding or support for fellowships from teaching hospitals or academic centers that receive educational support from Medicare, (2) conduct most services in a nonprovider setting or a freestanding clinic that has no written contract with a teaching hospital, (3) charge fair value for fellows' services, and (4) use reimbursement from fellows' services for salaries, fringe benefits, basic equipment, loupes, cameras, meetings and travel, photography expenses, malpractice premiums, computers, secretarial services, and other practice-wide research and educational activities.
The financial impact of a private-practice fellowship program in an orthopaedic subspecialty can be exemplified by the following information from the Indiana Hand Center.
The Indiana Hand Center has ten orthopaedic hand surgeons on staff and employs six fellows (including one from another country) annually. Its surgeons perform more than 6000 operative procedures per year, of which approximately 80 percent are done at a freestanding surgery center that is integrated with the Indiana Hand Center.
The fellowship program at the Indiana Hand Center is accredited through the Department of Orthopaedic Surgery at the Indiana University School of Medicine, and fellows' salaries and total expenses are paid entirely by the Hand Center. The fellowship program receives no funding whatsoever from the Indiana University Medical Center or from any other hospital, and none of the fellows are included in any full-time-equivalency count of residents for Direct Graduate Medical Education payments. There is no written agreement between the hospital and the Indiana Hand Center indicating that the hospital bears the costs of the residents' or fellows' time in the nonprovider setting. All fellows have regular staff privileges at St. Vincent's Hospital, which is the most frequently used private hospital for Indiana Hand Center services. More than 80 percent of all fellows' services are provided at the Indiana Hand Center, and both Indiana Hand Center and hospital services are billed for at a reasonable rate.
Medicare and Medicaid represent 16 percent of charges and 7 percent of collections at the Indiana Hand Center. The collection rate of fellows' charges is about 50 percent. Salaries and benefits, malpractice insurance, secretarial expenses, travel costs, photography, and other fellow-related expenses consume about 35 percent of the collected funds for fellows' services, and 36 per cent of what remains is spent for taxes. Nonetheless, the Indiana Hand Center has always had sufficient remaining dollars to fund substantial practice-wide research and educational activity.
Attorneys for the Indiana Hand Center are familiar with all of the rules of the Health Care Financing Administration, and in 1997 they reviewed the contract that is used for fellows at the Center to ensure that it complied with the newly enacted guidelines of the Accreditation Council for Graduate Medical Education. With regard to billing for patient services, the attitude of the attorneys for the Indiana Hand Center is that the fellows are totally funded by the Center and their services are contracted for by the Center; therefore, the Center may justifiably bill for those services. The attorneys are confident that no rules are being violated. They are aware of some contrary interpretations by other agencies and, to date, view them as unsubstantiated, untested, and self-serving.
Private-practice fellowships may be a very practical option for decreasing institutional budget lines for fellowship training. If structured properly, they have many advantages for both fellows and staff and can result in an extremely high level of patient care and an excellent educational experience that includes areas of practice organization and management that are beyond the scope of most academic fellowships. Funding through private sources or reimbursement for fellows' services is feasible but requires flexibility, an appreciation of the existing rules, and the ability to act rapidly in response to changes in these rules.
The private-practice fellowship requires a high level of cooperation from the hospital in areas such as attaining privileges and appointments. The Indiana Hand Center may be unique in this respect, having had excellent cooperation for its training program from St. Vincent's Hospital and the Orthopaedic Department at the Indiana University Medical Center. Surgeons in other settings may be find hospitals or their professional staffs to be less inclined to cooperate in matters such as staff admitting privileges.
When organized correctly, excellent post-residency subspecialty training can be achieved in either an academic or a private setting. Both settings will have to adjust the structure of their programs as regulations and financing change.
Address for Dr. Strickland: Department of Orthopaedics, Indiana Hand Center, University of Indiana, 8501 Harcourt Road, P.O. Box 80434, Indianapolis, Indiana 46280.
I have been asked to provide an overview of the approaches that other specialties have developed to graduate medical education in their subspecialties and to identify some of the similarities and differences that they may have with the manner in which orthopaedic surgery education has evolved since accreditation of fellowships was initiated in 1985. To let you know where I am headed, my presentation will follow a five-point outline. First, I will review some historical data from the archives of the Accreditation Council for Graduate Medical Education. Second, I will give you the most recent numbers for accredited orthopaedic fellowships and residencies. Third, I will highlight a few of the policies and procedures that the Accreditation Council for Graduate Medical Education and its Residency Review Committees have adopted in the area of the subspecialty accreditation. Fourth, I will give you a sampling of the manner in which other specialties approach subspecialty certification and accreditation. Finally, I will review some of the issues that most specialties, including orthopaedics, find important as they continue to evaluate and refine their activities in subspecialty education.
Although a small number of subspecialty programs were accredited during the 1950s and 1960s, it is apparent that the accreditation of subspecialties was a very small part of the accreditation enterprise until the 1980s (Table III). Then, while the field of orthopaedic surgery was putting together its request for approval from the Accreditation Council for Graduate Medical Education to initiate the accreditation of its fellowships, most other specialties became involved in similar efforts. Today, the number of accredited subspecialty programs (3436 in sixty-two subspecialty areas) continues to grow and is beginning to approach the number of programs in the specialty areas (4138 in twenty-six specialties).
To give you a sense of how orthopaedic surgery fits into the larger universe of graduate medical education, the 180 orthopaedic fellowships accredited by the Accreditation Council for Graduate Medical Education (Table I) account for about 5 percent of the total number of subspecialty programs accredited by the Council. The number of accredited orthopaedic fellowships exceeds the number of accredited orthopaedic surgery residencies, which is currently 157.
When the first subspecialty programs sought and received accreditation back in the 1950s, they were reviewed as freestanding programs that were not necessarily related to or dependent on an accredited residency program. When you take a look at the institutions where most of the programs were located (blood banks, medical examiners' offices, and pediatric hospitals, for example), that was a logical approach. More recently, specialties such as internal medicine have entered the subspecialty arena and have required their fellowship programs to be provided by institutions that also sponsor an accredited medical residency. As a result, the Accreditation Council for Graduate Medical Education requires its Residency Review Committees to select one of two approaches to subspecialty accreditation: (1) all subspecialty programs accredited by the Residency Review Committee must be directly dependent on an accredited residency program, or (2) all subspecialty programs accredited by a Residency Review Committee must be reviewed as a freestanding, independent program.
When the Residency Review Committee for orthopaedic surgery was faced with this choice in the mid-1980s, many of the best known pediatric orthopaedic fellowships, in particular, were sponsored by institutions that did not offer orthopaedic residencies; thus, it was ultimately agreed that orthopaedic fellowships would be accredited as independent programs. Now, as most of you know, when orthopaedic fellows and residents are being trained in the same location, the Residency Review Committee asks fellowship and residency directors to develop a statement regarding the manner in which they will ensure that the fellowship has a complementary impact on resident education. However, when a fellowship is granted accreditation, that status is unrelated to the accreditation status of any related orthopaedic residency.
Several other policies of the Accreditation Council for Graduate Medical Education have importance for orthopaedic fellowships, including the following.
1. Accreditation will be approved only in the subspecialty areas that are bodies of knowledge (not techniques such as arthroscopy). Therefore, although some of the programs listed in the American Academy of Orthopaedic Surgeons' fellowship book3 identify themselves as arthroscopy fellowships, these programs are not eligible for accreditation by the Residency Review Committee of the Accreditation Council for Graduate Medical Education.
2. All individuals appointed to programs accredited by the Accreditation Council for Graduate Medical Education (both residencies and subspecialty fellowships) will be identified as residents. In part, this is due to the fact that most government regulations recognize residents rather than fellows. Clearly, this causes some confusion within the orthopaedic community, and when you talk with me or another member of the Committee we will certainly use the term fellow. However, official communications from the Accreditation Council for Graduate Medical Education and its Residency Review Committees will use resident and residency rather than fellow and fellowship.
3. All accredited orthopaedic subspecialty programs must be twelve months in duration. Again, this requirement places some of the programs listed in the Academy's fellowship publication3 outside the realm of the Accreditation Council for Graduate Medical Education. This does not mean, however, that the programs cannot or should not continue. They are just not eligible for accreditation by the Residency Review Committee.
4. Finally, the Accreditation Council for Graduate Medical Education does not permit Residency Review Committees to accredit fellowships that are predominantly research experiences. The Accreditation Council for Graduate Medical Education has always seen its mission as the accreditation of programs that prepare physicians for activities related to patient care and does not believe that is the appropriate group to evaluate the quality of a program that is devoted primarily to basic or clinical research, or both. Therefore, whereas the Residency Review Committee expects fellows in accredited programs to participate in research, the principal purpose of the fellowship must be the preparation of fellows for clinical practice.
If we classify medical subspecialties in terms of whether accreditation by the Accreditation Council for Graduate Medical Education or certification by the American Board of Medical Specialties, or both, was available, there are four possible categories: certification with accreditation, no certification or accreditation, certification without accreditation, and accreditation without certification.
Certification with Accreditation
More than 90 percent of the programs accredited by the Accreditation Council for Graduate Medical Education fall into this category, as do more than 95 percent of the programs in subspecialty areas in which American Board of Medical Specialties certification is available. Therefore, the greatest number of subspecialty programs offered by other specialties are in areas in which both certification and accreditation are provided.
No Certification or Accreditation
Virtually every specialty has some subspecialty programs in areas in which neither certification nor accreditation is provided. For example, there are a large number of fellowships in surgical pathology, surgical dermatology, family practice/obstetrics, and family practice/adolescents. The Accreditation Council for Graduate Medical Education does not provide accreditation of any of these programs, and individuals who complete them are not eligible for any type of certification by the American Board of Medical Specialties. I think that the main reason that neither certification nor accreditation is offered is that the areas are not seen as subsets of the larger specialty. Clearly, there are parallels here with the perspective of some orthopaedists. During the early 1980s, for example, many within the orthopaedic community were concerned that fellowship accreditation would fragment the specialty. Furthermore, some feared that hospitals might restrict privileges in some areas to orthopaedists who had completed an accredited fellowship. I do not think that fellowship accreditation has been detrimental to orthopaedics during the last ten years, but some continue to be reasonably concerned about fragmentation and fellowship-based decisions regarding privileges.
Certification without Accreditation
The only subspecialties in this category are maternal/fetal medicine, reproductive endocrinology, and gynecological oncology. About ten years ago, the American Board of Obstetrics and Gynecology began to review and approve the approximately 100 fellowships in these areas. Although accreditation by the Accreditation Council for Graduate Medical Education in these three areas is not available, individuals who complete programs approved by the American Board of Obstetrics and Gynecology may sit for a certification examination. To date, the American Board of Obstetrics and Gynecology has been satisfied with this approach, and those of you who think that musculoskeletal specialty societies should review and approve orthopaedic fellowships might be especially interested in this model. There are some contrasts with orthopaedics (for example, only 5 to 6 percent of those who complete residencies in obstetrics and gynecology go on to fellowships) and potential difficulties (it might be difficult for smaller societies to be rigorous with programs directed by individuals who are highly regarded within the specialty, for example), but it is an approach that the American Board of Obstetrics and Gynecology expects to continue.
Accreditation without Certification by the American Board of Medical Specialties
As many of you will remember, orthopaedic surgery was the first specialty to receive approval for this approach, and it was considered fairly radical when it was first suggested in the early 1980s. Currently, this approach is also being used in two relatively small areas (pediatric urology and craniofacial surgery), but orthopaedics continues to be the only specialty that provides accreditation for a relatively large number of programs in areas where certification is not available. At this point, I think that the approach is fairly well accepted, and unless a change is requested by the orthopaedic community I would expect that its fellowships will continue to be eligible for accreditation by the Accreditation Council for Graduate Medical Education even if the American Board of Orthopaedic Surgery does not request approval for certification.
Those of us in the field of orthopaedics can learn quite a bit from the experience of other fields, even if there are no obvious answers to all of the questions that you are asking as you assess your current approach to fellowships. The broader perspective does, I think, confirm that you are wrestling with the right issues, five of which I would like to highlight as I conclude.
Relationship of the Orthopaedic Specialty to its Subspecialties
I do not think that ten years of fellowship accreditation has fragmented orthopaedics or prompted hospitals to require fellowship training for orthopaedic privileges; however, the relationship between orthopaedics and its various subspecialty areas is something that deserves careful attention as you assess your current fellowship activities. Clearly, this relationship is an important topic to be included in any debate about possible certification by the American Board of Orthopaedic Surgery in any new subspecialty area.
Relationships to Other Specialties and Subspecialties
The relationship of hand surgery to orthopaedics really is not different from that of the other subspecialties. However, the fact that plastic and general surgery would probably offer certification even if the American Board of Orthopaedic Surgery did not is the most obvious example of how the relationship between orthopaedics and other specialties needs to be considered as you plan your fellowships of the future. In particular, you are going to need to pay attention to the accreditation and certification activities in sports medicine that are already under way in the primary-care specialties. Also, if neurosurgery were to initiate accreditation or certification, or both, in spine surgery, I am certain that the Residency Review Committee and the American Board of Orthopaedic Surgery would be vigorously encouraged to provide similar recognition for orthopaedists.
Funding
Given the recent activities of the federal government and the other agencies that provide funds for graduate medical education, fellowship funding is becoming increasingly complex. Unfortunately, this may get worse before it gets better, and I am afraid that funding regulations may drive some out of the fellowship business. I am not a funding expert, but I do know that issues in this area will be crucial to the future of orthopaedic fellowships. I hope that the problem of funding will not completely overshadow the educational issues that should also a part of your assessment.
Quality of Applicants
One of the benefits that accreditation has provided for many programs has been a steady supply of very well qualified candidates. Although the well known nonaccredited programs continue to attract good fellows as well, many residents focus their interest on the accredited programs.
Quality of Fellowships
Finally, I think that ten years of accreditation has prompted a considerable improvement in the quality of orthopaedic education at both the residency and the fellowship level. I might add that a lack of recognition by the Accreditation Council for Graduate Medical Education has not been the death knell for fellowship programs that have chosen not to apply for accreditation. Many of those that have submitted themselves to review by the Residency Review Committee, however, have evolved dramatically from relatively unstructured clinical preceptorships into well organized educational programs that have strong academic, research, and clinical components.
Address for Dr. Nestler: Residency Review Committee for Orthopaedic Surgery, Accreditation Council for Graduate Medical Education, 515 North State Street, Suite 2000, Chicago, Illinois 60611. E-mail address for Dr. Nestler:spn@acgme.org.
Dr. Simon: As Steve Nestler mentioned, one of the things that differentiates fellowships in orthopaedic surgery from those in most other specialties is that they are all one year and none but those in hand surgery lead to a certificate. Most of the other fellowships—in medicine or pediatrics, for instance—are two or three years in length, have a major research component, and have a Certificate of Special Qualifications or a Certificate of Added Qualifications. One of the main issues that we on the Residency Review Committee see is that some fellowship programs are withdrawing their accreditation. I will ask Jim Strickland to comment. I think that the premise underlying withdrawal is that the programs would be able to bill for their fellows' services. What is your interpretation?
Dr. Strickland: I find that very confusing. It comes from one interpretation, and there are many interpretations out there. Probably the most confusing interpretation comes from a document that has been circulated by the associate regional administrators, Division of Medicare, from Barbara O. Wynn, Acting Director of the Bureau of Policy Development, Association of American Medical Colleges, in February 199718. Where her interpretation came from is hard to say. That interpretation and some other interpretations indicate that accreditation alone limits the ability to bill for fellows' services, regardless of whether the fellowship pays money to those fellows or not. Our attorneys cannot find how or where that applies or the legitimacy of that statement. If it is true, then I can see why fellowship programs would want to eliminate their accreditation. If fellowship programs comply with the regulations in all other ways, that would permit the programs to bill for fellows' services. I believe that this interpretation needs to be challenged. I think it is untested that, if a program is accredited, the institution cannot bill for fellows' services, regardless of the setting or the type of reimbursement the fellows get. Jim, is that your understanding?
Dr. Herndon: There are a couple of principles here. You have to remember that the Health Care Financing Administration and Medicare really have a very poor understanding of what is going on in the marketplace in terms of funding. For instance, the direct payment for residents varies across the board from around $60,000 to over $2000,000 a year. There are several ophthalmology hospitals that receive $200,000 a year in direct funding per resident. The Health Care Financing Administration is just uncovering this piece of information. That is coupled with the Medicare Restore Trust, in which the Clinton White House is trying to underwrite the losses of Medicare, which is still expected to go bankrupt after the year 2002.
The Health Care Financing Administration is looking at all kinds of ways to recover money. I will give you an example. The Health Care Financing Administration really does not want to see any crossover between Part-A and Part-B dollars. That is easy for them to understand, so the Health Care Financing Administration is going to insist on that. It doesn't apply to Jim Strickland's program, but it does to any academic program. If a resident reduces a radius fracture in the emergency room at three o'clock in the morning, there is no bill for that in our institution, except maybe from the emergency room physicians. The next day, I have an elective procedure to perform. I do that closed reduction in the operating room, and I have the same resident with me. The Health Care Financing Administration has raised the issue that I am not able, therefore, to bill for that patient because I allowed a resident to perform the operation without my supervision on one occasion and on the next occasion I did it and billed for it. The Health Care Financing Administration is looking at all kinds of ways to recover dollars. That is under discussion now. I just wanted to set the stage for what they are thinking.
Dr. Richard Gross, Charleston, South Carolina: I am Dick Gross from Charleston, and I want to address what seems to be an increasingly rigid one-year time requirement. The speakers mentioned different reasons for taking fellowships, such as perceived deficiencies in a residency program or just to improve one's knowledge in a certain area. To do this does not necessarily require a year. It seems that some flexibility is needed because a resident may want to spend a few months working in a certain area so that he or she can emphasize that area in his or her practice without becoming a subspecialist.
Dr. Cooper: Personally, I think you are correct. As Jim Herndon and some of the others mentioned, one does not necessarily need a year to specialize in a particular practice area. As Steve Nestler said, the rules that the Accreditation Council for Graduate Medical Education handed down to the Residency Review Committee state that, if we are going to accredit a program, it must be for one year. One can have a nonaccredited fellowship if one wants and set one's own time. I agree that if one wants to subspecialize in some areas, it does not take a year.
Dr. Simon: I will ask another question of the panel: What do you think about the concept of other orthopaedic societies accrediting fellowships?
Dr. Cooper: I would like to take a crack at that one because I have a strong opinion about it. I think that it is very dangerous for certain reasons. In this country, accreditation of higher education comes under the Department of Education in the federal government, under the Commissioner of Education. They have delegated to various agencies the accreditation of higher education. The North Central Council accredits the colleges in the north central area, et cetera, and they have delegated to the Accreditation Council for Graduate Medical Education the accreditation of graduate medical education. So that is the established route, whether good, bad, or indifferent. I also think that the Residency Review Committee for orthopaedic surgery, especially with Steve Nestler and its specialist site-visitor program, has done an outstanding job of establishing guidelines and coming up with reviews that stand up against challenges in courts. I think that, if subspecialty societies accredit fellowships, they will probably have a more restrictive view than does a broader-based group and they will make rules that will indeed unduly limit what the general orthopaedist can do. I think it will lead to further fragmentation. I don't know why we want to create any more problems within orthopaedics when we've solved some of the problems that we've had in the past. I think that we have enough imposed upon us by the federal government and by managed care and other health-care organizations.
Dr. Bergfeld: I am a fan of the Residency Review Committee and the Accreditation Council for Graduate Medical Education, so I personally believe that accreditation by the Residency Review Committee is good. What we gathered from our survey was that only 60 percent agreed. One opinion was that there weren't enough of their own subspecialists in the review process. In other words, a thoracic surgeon reviewed a fellowship in sports medicine. The number of orthopaedic specialists who have confidence in the Residency Review Committee process might increase if we could involve ourselves, orthopaedic surgeons at least, in the review process.
Dr. Nestler: At the present time, orthopaedists and nonorthopaedists do site visits for the Accreditation Council for Graduate Medical Education and the Residency Review Committee for orthopaedic surgery. We do have a project that is a little bit different from some other specialties because, about ten years ago, we started a program in which we identified about fifteen to twenty people; these were orthopaedists who would spend the time to come to a training program. At that time, when we started out, we thought that they would do maybe three or four visits a year. I think that years ago it was easier for orthopaedic surgeons to leave the office and do something for their profession than it is today. Now we have fifteen to twenty orthopaedic surgeons who are doing about two, sometimes three, visits a year. That takes care of about half of the site visits that we need to do to keep up with all of the fellowships and residencies. So, not everybody gets a site visit. We try to rotate the visits, if we can, so that maybe an orthopaedist visits one time and a nonorthopaedist visits the next time. Site visitors have different strengths and weaknesses. The people who are nonorthopaedists are those who work for the Accreditation Council for Graduate Medical Education, either half-time or full-time, and they are experienced. Even though they are not orthopaedists, I think that they can do a good job.
Dr. Simon: The members of the Residency Review Committee who make the decisions are all orthopaedic surgeons. There are nine orthopaedic surgeons on the Residency Review Committee, and two of them presently have a subspecialty interest in sports medicine. I think that, to help that process, maybe our sports medicine society should try, through the parent organizations of the Residency Review Committee, to get more orthopaedic surgeons who have an interest in sports medicine to be on the Residency Review Committee. The orthopaedic surgeons who are members of the Residency Review Committee are the ones who make the decisions; site visitors prepare the reports.
Dr. Cooper: There is another thing in John Bergfeld's survey that I forgot to point out. I think that he said that 40 percent didn't understand what accreditation and certification were, so I don't know how 40 percent could make the decision on who should accredit if they don't know what accreditation is.
Dr. Bergfeld: I agree with that, but where it comes from is this: the fellowship director, who may not be a real academician in a university center, has a thoracic surgeon review the program. All the fellowship director knows is that a thoracic surgeon reviewed the program. He or she doesn't know the process and doesn't know that the report went back to, and the decision was made by, orthopaedic surgeons. Maybe one of the problems that we have identified for sports medicine that we could solve is that we need to educate the directors of fellowship programs.
Dr. Carl Stanitski, Detroit, Michigan: Jim Strickland gave an elegant presentation. The question in my mind is how applicable that system is to fellowships that are not in areas such as hand and foot (in which most of what one does can be done on an outpatient basis), but rather are in subspecialties such as total joint replacement, trauma, and pediatric orthopaedics that require inpatient services. These subspecialties require a hospital setting, and the fellow must become directly affiliated with the hospital in some way. This is different from being able to practice in an isolated unit such as your hand center in Indiana. How would you suggest that other subspecialties handle the problem? Also, something that is faced by many of the academic centers is a huge Medicare or Medicaid load.
Dr. Strickland: Your question is a superb one. Unfortunately, if a majority of a practice is carried out in a hospital and that hospital receives federal support, then I think the hospital is in murky water when it tries to bill for the services of the fellows, regardless of whether the fellows are included in the Graduate Medical Education count. There is an interpretation that says that, even if the hospital could include them in the Graduate Medical Education count, it ought not to be able to bill for their services. Now, there are other shades of gray, where a portion is carried out in a private setting not contracted for by the institution and a portion is in the hospital. What is a substantial amount that allows the institution to bill, and what is not? I really think that there is a need for individual case interpretations by an attorney who is familiar with these situations, and there are many such attorneys. Luckily, we have a fairly clean situation at our hand center in Indiana. I think that there are some situations that aren't clean, ones in which an institution can work toward isolating the fellows to set up a much cleaner ability to charge for patient care.
Dr. Herndon: Two things, Dr. Stanitski. One is that it is very difficult because the rules are changing on how the direct and indirect payments are being paid to the hospitals by Medicare. Currently, there are two ways to do that, and I'm not advocate of either. First, if the fellow is moonlighting in another field in the hospital, the fellow can bill. Second, because Medicare is encouraging outpatient experiences, if residents moonlight or even work in an outpatient facility it may be possible to bill. It is not clear and hasn't been tested. There is some suggestion by the Health Care Financing Administration that they can bill. But those rules are very confusing, and I wouldn't suggest that you try to bill. Talk to your attorneys.
Given that subspecialization is an inexorable process in the advancement of society and, in particular, medicine, it is only natural that society needs, and physicians and surgeons demand and promote, the process. Subspecialty fellowships fulfill the desire of orthopaedic surgeons to improve patient care, education, training, and research. Presently, more than 60 percent of orthopaedic residents take a fellowship in some area of subspecialization to obtain extra training in an area of interest; to gain more confidence in their skills; to obtain more attractive jobs; in some instances, to address inadequacies in resident education and training; and, possibly, to enhance economic well-being. Almost all agree that subspecialization and subspecialty training, through fellowships, enhance knowledge and technology and improve patient care.
Fellowships can, and do, enhance the education of residents when appropriately balanced by the cooperative efforts of the respective program chairpersons. Fellows are able to aid in the care of a high volume of patients who have special medical needs. If appropriate services are used, specialty trainees provide cost-effective care. Fellows and fellowships develop improvements in knowledge and technology, thus enhancing patient care.
There are some drawbacks to subspecialization in orthopaedic surgery and its accompanying fellowship training and education. If not appropriately managed, fellowships can have a negative impact on resident education when the relationship between the residency and the fellowship is not closely monitored. Some of the fellows are just surgical assistants, and the fellowships are without any educational program or investigative effort. Fellowships, and thus subspecialization, increase fragmentation of knowledge and research and therefore have the potential of increasing both costs and malpractice litigation in the workplace. Subspecialists may fail to consider the general needs of patients and may be too technically or procedure-oriented, resulting in too many or unnecessary operations. Furthermore, subspecialists may try, for economic reasons or self-interest, to exclude others from certain privileges. Finally, research funding and publications are fragmented by subspecialization so that a broad view of the needs of our patient population becomes obscure.
The difference between accreditation and certification is not readily understood by most orthopaedic surgeons. Accreditation is a process whereby an external group evaluates an educational program. On the other hand, certification is a confirmation, usually by a test, of an individual's knowledge that is provided to assure the public that the individual has obtained the necessary knowledge to care for patients. Accreditation is almost uniformly administered by the Accreditation Council for Graduate Medical Education through the Residency Review Committee, so that the members of specialty societies do not act in self-interest and so that educational criteria are paramount. Accreditation by specialist societies is fraught with self-interest and possibly successful legal challenges on the premise of restraint of trade. Certification examinations are administered by a different, independent body called the American Board of Orthopaedic Surgery. Specialists' self-interest is muted by this independent system of peers. Thus, this method protects the interest of the public and defers any governmental role, which occurs in almost all other industrialized nations. These voluntary independent bodies do not always represent the interests of the specialists, and that is where conflicts may occur from time to time (for example, in the process of recertification in the 1980s and now in the area of Certificates of Added Qualifications).
Fellowship funding is under duress and undergoes continual change because of changes in the Medicare reimbursement policy. No matter how one interprets the changes in the law, funding will continue to decrease. It is likely that the number of fellowships will decrease because of economic imperatives and that practice income, private donations, or even fellows themselves will have to support their own salaries. Physicians are very creative, and they will have to find methods to support fellowships economically.
Because of concerns about fragmentation of the specialty and about funding of fellowships, some have suggested incorporating the fellowship into the final year of the residency. Present funding by the government would, at least temporarily, be ensured, and there would be a decrease in the costs of education to the individuals and the programs. However, many residencies lack the breadth and depth of faculty and clinical material to have such a radical change. If one subscribes to the concept that a generalist needs five years of postgraduate education, there is also a concern about the potentially negative impact on resident education. This might be a workable solution only if earlier specialization in the final year of medical school is facilitated.
There are many types of post-residency educational experiences that fulfill the needs of residents and society. Most orthopaedists certainly do not need a Certificate of Added Qualifications because the goals are limited. Preceptorship, especially for a short period, is one type of limited fellowship. These types of fellowships are still prevalent and do not, and should not, lead to accreditation or certification. Accreditation of the one-year specialty fellowships by the Residency Review Committee is necessary to assure the public and our orthopaedic specialty that we have the highest educational standards.
The ideal fellowship from the viewpoint of the public and our specialty is a three-year fellowship that includes a two-year mandatory investigative arm, possibly leading to an advanced degree. These fellowships would advance knowledge in our specialty more than do the present one-year fellowships, and they would provide our specialty with its future academic leaders. Only these individuals should be eligible for certification examinations. The funding of this type of fellowship would be very limited and would require sources different from those now available.
The issues related to fellowships in orthopaedic surgery are not unique to our specialty. There is constant, healthy tension between subspecialists and specialists that needs to be monitored. Funding issues will be sources of constant turmoil for the next five to ten years, but I hope that educational quality will not be forgotten. In a relatively short period of time, the accreditation process has made fellowships less chaotic and has improved the educational content of fellowships from unstructured preceptorships into many well organized educational programs with strong clinical and academic components. For the future, our specialty needs a few three-year fellowships of even higher quality with a strong research component. Only in this fashion can we train and educate future investigators who will advance our specialty and promote the orthopaedic health of the public.
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