AANS Neurosurgeon | Volume 29, Number 2, 2020

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A Combined Spine Surgery Fellowship

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A combined spine surgery fellowship is ill defined. For most, it means there is a dedicated clinical rotation on the neurosurgery and orthopedic surgery spine services. This arrangement may provide a broad exposure to multiple surgeons, yet limitations remain. Most often, two fellowships exist, one neuro and one ortho, each with its own fellowship director and recruitment plan. Overlap may exist in the interview process and even recommendations, yet two programs exist. The two-leader construct poses problems when there is disagreement upon curriculum, graduation and programmatic design. One of the most significant issues is the impact on the resident training program and development of a unified spine service.

The Cleveland Clinic began its efforts to unify spine in 2001; before that time, two fellowship programs existed in complete isolation with limited cross-over rotations. There was no crossover of residents: neurosurgery residents did not work with orthopedic surgery staff. The Cleveland Clinic Spine Institute formed in 2001 setting the stage for a truly unified fellowship. Under the institute model, all spine care providers were placed in a service line-based department under one leadership. This included ortho- and neurosurgery spine surgeons as well as PMR, rheumatology, neurology and pain psychology. The spine surgery fellowships were combined. Specifically, one fellowship was created; all surgical staff became faculty for both orthopedic and neurosurgery fellows. Didactic conferences and fellow evaluations were consolidated.

Our unified fellowship has continued to evolve and address challenges in a dynamic manner. We have held a debriefing with each fellowship class upon completion of the year. We have faced challenges around recruitment and the Match. Ortho spine fellowship candidates enter into the “Match” process and thus require dedicated interview dates and creating a match list. To some extent this process is more competitive than to neurosurgery and similar to residency interviews. Many candidates are invited and interviewed on predetermined dates. As neurosurgery is not part of a “Match”, we are able to interview candidates on a rolling basis. It is typical to interview  between one to three candidates. We have found offers for neurosurgery candidates continue to be done earlier in the training program. In the past, we interviewed all candidates at the same time and offered positions at the same time. We found that many of the neurosurgery candidates we planned to interview had already accepted positions in traditional neurosurgical programs. Thus, we now interview the neurosurgery candidates separately, earlier than our ortho group, and offer positions on a rolling basis. 

Over the years, we have attempted to address and mitigate conflict between fellow and Chief Residents in regards to coverage of surgical cases.  We have altered this process many times over the years, and our current strategy appears to be very effective. We have created a completely unified spine service, specifically fellow and neuro and orthopedic residents. The goal is appropriateness and fairness based on level of training; the entire program focuses on education and not pedigree. The spine fellows and neurosurgery chief residents play a critical role in educating the junior trainees.

With 15 years’ experience in combined fellowship, we have learned that graded autonomy of the fellows is effective.

Strong leadership, constant re-evaluation and a collaborative surgeon group are paramount to a combined spine fellowship. The group must function under a single vision in order to be successful.

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