Every year as their residencies end, more than 120 neurosurgeons make the decision to continue their training in the form of a fellowship. But, what exactly is a “fellowship,” who sets the curriculum, is anyone measuring the quality of the programs and what do residents gain by pursuing this additional training?
The American Association of Neurological Surgeons/Congress of Neurological Surgeons Task Force on Fellowships was formed in April of 1997 by the Joint Officers after a series of fellowship-related resolutions advanced by the Council of State Neurosurgical Societies (CSNS). The Task Force was chaired by Julian Hoff, MD, and submitted its final report to the AANS/CNS Joint Officers in January, 1998.
The members of the Task Force included: Frederick Boop, MD; David Jimenez, MD; James Bean, MD; Stewart Dunsker, MD; Hunt Batjer, MD; Kim Burcheil, MD; and Stephen Haines, MD.
“Fellowships are definitely a rising trend in neurosurgery and there’s a growing concern about who and how these fellowship programs are being monitored for quality,” Dr. Hoff said. “This is an issue that needs to be addressed by organized neurosurgery.”
Conclusions
During its 9-month investigation, the Task Force polled neurosurgical residents, program directors, and other medical specialties about fellowships, quality standards and accreditation. Based on its research, the Task Force developed four general conclusions about neurosurgical fellowships:
- The natural and historical trend in medicine has been toward subspecialization. Survey data from within neurosurgery as well as other surgical and medical subspecialties suggests that this trend will continue.
- Other surgical subspecialties offer formal guidelines for fellowship training and monitor the quality and impact of these fellowships. In orthopedics, for example, the Residency Review Committee (RRC) is charged with monitoring and credentialing fellowships.
- Surveys of current residents, chief residents, and recent graduates suggest that between 20 and 25 percent of graduating neurosurgeons plan to enter fellowship subspecialty training. Currently, at least 127 neurosurgical fellowships are offered in the United States in 10 different areas of subspecialization. These fellowships last from 3 months to 2 years, have no minimum quality standards established, and little data exists as to their impact upon residency training or the practicing community. Given their prevalence, it is recognized that mechanisms need to be established to develop guidelines for fellowship training in neurosurgery and to insure a consistent quality product for the trainees.
- The practicing neurosurgical community is opposed to formal subspecialty certification, feeling that it will confer an unfair market advantage against the non-subspecialty trained neurosurgeon and that it may place them in medicolegal jeopardy.
Recommendations for Action
Based on these conclusions, the Task Force made five recommendations for action.
These recommendations have been approved and accepted by the AANS Board of Directors and the CNS Executive Committee.
Recommendation One: Definition of “Fellowship.” A fellowship is defined as specialized training and acquisition of skills beyond ordinary residency training requirements and should occur within an ACGME accredited institution, but not necessarily within an ABNS approved neurosurgical training program. It should occur later than the PGY-4 and should be distinguished from the general residency training, and focused upon a particular area of interest within the scope of neurosurgical practice such as neurotrauma, endovascular, spine, cerebrovascular, tumor, pediatrics, skull base surgery, pain or functional and stereotactic surgery.
Recommendation Two: Fellowship Content. Written guidelines should be developed by the appropriate AANS/CNS Joint Section for each type of fellowship. The Residency Review Committee (RRC) should review and approve this curriculum and oversee its implementation.
Several Joint Sections, including Pediatrics, have all ready developed written guidelines for fellowships in their area of interest. Once approved by the RRC, these guidelines will be used to monitor programs for content and quality.
Recommendation Three: Fellowship Duration. The Task Force felt that a formal fellowship should be a minimum of 12 months duration. Focused educational experiences of shorter duration occurring prior to residency, during residency (elective rotations), or following residency should not be considered fellowships. There are approximately 26 existing fellowship programs, including 9 spine and 8 functional, that are less than 12 months in duration. The remaining programs are currently between 12 and 24 months. Approximately 95 percent of fellows polled felt their fellowship was adequate in length.
Recommendation Four: Qualifications and Responsibilities. The RRC should establish faculty qualifications and responsibilities for fellowship training. Furthermore, it was felt that the RRC would be the most appropriate body to develop institutional requirements for fellowships and to monitor their quality, in addition to their impact, upon residency training. Once this process is established, fellowships should be accredited through the RRC.
Recommendation Five: Certification Criteria. Because we do not currently know how to monitor competence, and because the neurosurgical community remains opposed to national certification of fellowships, certification criteria for fellowships must presently remain at the institutional level.
The American Board of Orthopedic Surgery (ABOS) currently recognizes eight areas of fellowships – hand, foot and ankle, pediatrics, musculoskeletal, oncology, reconstruction, trauma, sports medicine and spine, but the only subcertification given is a Certificate of Additional Qualifications in Surgery of the Hand. This certificate is given in conjunction with the American Board of Plastic Surgery and American Board of Surgery.
In neurosurgery, the AANS/CNS Joint Sections have been created to address the issues of the subspecialties. There are Joint Sections on pediatrics, cerebrovascular surgery, tumors, trauma and critical care, stereotactic and functional, pain and spine. All of the Joint Sections have seen substantial growth over the years (please see chart 2) and many have formed their own executive committees, task forces, annual meetings, newsletters, research awards and policy statements.
The Next Step
The recommendations for action have been sent to the RRC for neurosurgery and the American Board of Neurological Surgery (ABNS) for review. If the RRC and ABNS approve and accept the recommendations, the process will begin to develop the quality standards, accredit programs and monitor institutions for quality. “At this point, we’ve made what we think are good, strong recommendations,” Dr. Hoff said. “We now need to wait for the RRC and ABNS’s comments and go from there.”