AANS Neurosurgeon | Volume 25, Number 4, 2016

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Value and Potential Disadvantages of Working in a Subspecialty: A Personal View

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You are already a specialist or in training to become one in an already highly specialized field. Why go further and become a subspecialist? I author this piece with a slightly conflicted view since I strongly believe every neurosurgical trainee should be exposed to a broad experience in all aspects of our specialty and, moreover, become competent in them. However, for the fully trained neurosurgeon, concentration of one’s practice, or a majority of it, in a specific area offers many advantages. This holds true not only for the neurosurgeon but also for the patients she or he serves, sometimes for our specialty, and occasionally for the broader aspects of medicine as a discipline.

Choosing a Subspecialty
Selection of an area of subspecialization is best done early in one’s training or practice. To succeed, I believe, it should become a passion almost similar to what you might have for a loved one or a close friend, or like what you might feel for your specialty as a whole. To do it well, you must master every nuance of your chosen area of concentration.

In my case, I was drafted into the U.S. Army Medical Corps in my second year of general surgery and assigned to a field unit in the Midwest. Since I did not wish to lose the surgical skills I had already become acquired, I sought additional work in a nearby military hospital above my field assignment responsibilities. Under some very unusual circumstances and after basic training camp in Texas, I was assigned to the Walter Reed Institute of Research and the Walter Reed Hospital. Despite a lack of experience in research, I was asked by Col. George Hayes, the chief of neurosurgery at Walter Reed, to develop a project that would evaluate possible species differences in regeneration after nerve injury and repair, and eventually to work on possible methods to improve results after nerve surgery. When I could, I attended office and ward rounds at the hospital and sometimes scrubbed in as either an observer or an extra pair of hands.

After two plus years in Washington, D.C., I returned to Ann Arbor where I received a further broad education in neurosurgery. After hours and on an occasional day off, I was able to work in Dr. Elizabeth Crosby’s laboratory using rhesus monkeys to further develop an intraoperative method of evaluating nerve injuries and other nerve lesions in continuity. These studies continued after I reached New Orleans and the Louisiana State University Health Sciences Center (LSUHSC) in July 1967. Multidisciplinary clinics for both public and private nerve patients were established as well as neurohistologic and neurophysiologic laboratories for research on nerve.

As the years went by, patient influx, especially for the private clinic, tended to concentrate on nerve cases. Fortunately, I still had responsibilities at Charity Hospital for a fairly large cohort of public cases, especially during the three to four months per year when I was the attending of record. Supervision of residents assigned there involved brain as well as spinal cases so I remained comfortable with the management of brain tumors, aneurysms, subdural hematomas, hydrocephalus and brain and spinal trauma.

The Opportunities From Subspecialization 
As others before me had found, subspecialization provided a good route for developing special interests within the field, publishing papers, giving talks and participating in panels at local, national and sometimes even international meetings. With nerve as a subspecialty, other disciplines involved in such meetings often included hand surgery, orthopaedic surgery, plastic surgery, neurology and sometimes even vascular surgery. As in other subspecialties, international involvement was likely and surprisingly even led pver time to a broader referral base for complicated patients needing care.

Many subspecialties also provide an opportunity to develop fellowships. In our case, this involved a multidisciplinary group including Drs. Tiel, Happel, Hackett and Sumner. Over the years, we had the privilege of having over 80 national and international fellows come to New Orleans for training in nerve for variable periods of time. Included were those in training not only in neurosurgery but also such other fields as hand, plastic surgery and orthopaedic surgery. Some fellows had already finished their training but chose to spend extra time learning about the management of nerve cases. It should be pointed out, though, that some neurosurgeons with special interest in nerve also have a robust practice in other neurosurgical areas, and I imagine that is also true in other areas of subspecialization.

Potential Responsibilities of a Subspecialist
If you are involved with resident training in your own neurosurgical program, it is very important to expose and be involved in a meaningful fashion with residents in your subspecialty cases. Training fellows should not exclude training residents. In my own case, nerve patients, especially those due to trauma, were not uncommon at Charity Hospital. As a result, there were many good opportunities for residents as well as fellows as there were in the private setting.

There can be local responsibilities for other patients outside your own subspecialty. You may be in charge of a more generalized service as I was for three to four months per year. You may be expected to take trauma call some nights and/or weekends. At times, those in the private sector of your community may insist that you care for patients not necessarily aligned with your area of concentration. You may be called upon by your institution or hospital to relate to neurosurgical or broader medical issues outside your subspecialty and be expected to be involved in such deliberations and/or resolutions. As a result, you have some responsibility to remain current in the literature relating to not only your subspecialty but to other less related areas as well. Of great importance, if you are in an administrative position as well as being a subspecialist, you cannot neglect the needs of those in your department, division or hospital unit who are in other subspecialties or who are neurosurgical generalists. Each of these responsibilities may take time away from pursuing your own subspecialty but are often necessary.

Recognition and Certificates of Special Qualification
Organized neurosurgery as well as the American Board of Medical Specialties (ABMS) have remained very involved in this process. Relatively early in this trend, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) established joint sections in a number of subspecialty areas. However, in 1986, only the area of Critical Care Medicine had four neurosurgery special qualifications, whereas the other specialty boards had approved recognition of 44 subspecialty areas (1).

Much has happened since the 1980’s when I was very involved in ABNS and ABMS deliberations on these matters, so I am no longer in any position to comment on the present situation for approval or recognition. However, organized neurosurgery, including the AANS, CNS and the Society of Neurological Surgeons (SNS), have established the CAST (Committee on Advanced Subspecialty Training), which has established very thoughtful guidelines for both the development and approval of subspecialty disciplines within neurosurgical programs.

If you can develop a passion or love for a subspecialty and can see yourself spending most of the rest of your professional life doing it, then pursue it with vigor. It may take extra time and expense and may be difficult to add to your other neurosurgical responsibilities it still is worthwhile. But do not forget that first and foremost you are more than a subspecialist; you are a neurosurgeon! I have not regretted the course that fell into my lap that I pursued with passion and that has given me a wonderful career

References
1. Kline, D.G., & Mahaley, M.S. (1986). Recognition of special qualifications in neurological surgery. Journal of neurosurgery, 64(4), 531-36.

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PHILIPP M LIPPE, MD, FACS, FAANS(L), FACPM | December 12, 2016 at 12:00 am

I greatly respect the viewpoint of Dr Kline, a colleague and friend. I agree that everyone claiming to be a neurosurgeon must be fully trained and competent in every facet of general neurosurgery. However, it is my impression that NS has been slow and reluctant to venture into sub-specialization. That is a mistake. In reality, we now have neurosurgeons who are proficient in and limit their practice to such areas as pediatrics, vascular, trauma, oncology, peripheral nerves, pain and others. For the most part the do so on an hoc basis adding a year or more of fellowship and/or years of apprenticeship. There is no forma certification and that is a mistake; witness the critical care debacle. It would be far better to establish formal structured didactic uniform programs capped by certification as most other specialties do.I believe all sub specialists should remain reasonably proficient in general NS. Take cardiology where the general cardiologist works with those sub-specializing in electrophysiology or intervention cardiology. For those who feel NS is too narrow a field in which to sub-specialize, I say look at the eye (no pun intended) where we see specialists in cornea, lens, retina, optics, macula, neuro, electrophysiology, and now vitreous and glaucoma. In all honesty, I believe NS is moving slowly towards sub-specialization, but the migration is too slow and too reluctant.