shoulder and elbow fellowships
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shoulder elbowTRANSCRIPT
Shoulder and Elbow Fellowships
Joseph P. Iannotti, MD, PhD
The primary aim of shoulder and elbow fellowship train-ing is mastery of evaluation and management skills. Be-cause a high level of proficiency requires advanced read-ing and (typically) involvement in research-related activi-ties, the implicit goal of these fellowships is to createshoulder and elbow experts. Fellows, if they have investedtheir time wisely, will graduate with abilities far abovethose of the typical community orthopaedic surgeon.
The first criterion for evaluating a fellowship is theadequacy of the surgical training experience. A graduatingfellow should master all types of rotator cuff repair; insta-bility procedures; shoulder and elbow joint replacement;and fracture care, spanning bracing to arthroplasty.
The fellow should attain expert level proficiency withthe arthroscope for both the shoulder and elbow. Althoughthe jury is still out regarding arthroscopic (versus open)rotator cuff repair, the consensus of the field is that manycases (impingement and instability for example) can betreated with arthroscopic methods. A fellowship that em-phasizes open treatment may be fine, so long as the men-tors are not narrow-minded about what the rest of theworld is doing—and offer training elsewhere (learningcenter courses, visiting rotations, etc).
If a given program does not cover the entire range ofshoulder and elbow conditions and treatments it is, tech-nically speaking, deficient; but that need not disqualify itfrom consideration. The fellow may have other oppor-tunities for learning these techniques. But more to thepoint, no fellowship can teach you everything. The processof being an expert in shoulder and or elbow surgery re-quires life long learning. The best fellowships foster thismindset and cultivate the attitudes and skills necessary toachieve it.
Some shoulder and elbow fellowships are that in nameonly; that is, they are primarily shoulder programs with
only minimal educational offerings regarding the elbow.There certainly is a role for such programs. For one thing,a fellow may wish to devote his or her future practice tothe shoulder, and would not be at a disadvantage havingonly minimum exposure to fellowship level elbow train-ing. In addition, a strong shoulder fellowship graduate willusually have no problem obtaining intensive elbow train-ing at another program after completion of the shoulderfellowship, if desired.
Fellowship applicants can probably be divided broadlyinto two types: those interested in the upper extremity, andthose with a sports medicine bent. Some applicants maywonder if they should apply for a sports or shoulder pro-gram. There is no pat answer. There are, of course, manysports medicine programs whose shoulder and elbow of-ferings are outstanding. In general, applicants shouldchoose a dedicated shoulder and elbow fellowship if theirinterests lie more toward management of degenerativeconditions and fractures of the shoulder; if they do notwant to be distracted by caring for other joints such as theknee; or have a particular interest in revision proceduresand operations on older patients with poor quality tissues.The answer ultimately comes down to the individual ap-plicant’s interests and the particulars of the program. As adepartment chairman, I would feel comfortable hiringsomeone as a shoulder surgeon who trained at a sportsmedicine program with an outstanding shoulder experience.
By definition, not all fellowships can be above average,and it might be asked, therefore, what characteristics(which can be discerned by the applicant) consign a pro-gram to the bottom half. For me, the red flag is a lack ofintrospective insight; that is, not being aware of the fel-lowship program’s own inadequacies. As noted above, in-adequacies in some areas are not disqualifying. Not rec-ognizing these inadequacies and working to improve them,however, is a fatal flaw. Similarly, I would be wary ofprograms which approach shoulder and elbow care in anexcessively dogmatic way. This may be inferred from alack of diversity in approaches to care. For example thereis more than one way to manage rotator cuff tears or trau-matic instability and these diverse approaches need to bepart of the training program.
From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation,Cleveland, OH.Correspondence to: Joseph P. Iannotti, MD, PhD, Department of Orthopae-dic Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland,OH 44195. Phone: 216-445-5151; Fax: 216-445-6255; E-mail: [email protected]: 10.1097/01.blo.0000224064.47614.b2
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A fellowship will no doubt be enhanced if there is anaffiliation with a basic science researcher working onshoulder and elbow problems, but this is by no meansrequired. More than anything, what a fellow needs is a setof teachers that maintain a skeptical attitude toward stan-dard practice and are open to discuss what they don’tknow. In a good fellowship, the fellow and mentors en-courage asking good questions, with an understanding thatsome of these questions do not have clearly defined an-swers—or, in some cases, any answer at all. A very goodfellowship works toward answering these questions. Thiscan be done through clinical research or comprehensivecritical assessment literature reviews. Basic science is onlyone facet of the process of finding good answers.
Shoulder and elbow education may be variably repre-sented at the various residency programs, and accordingly,some fellowship applicants may have had extensive priorexperience and some not at all. Residents in the first cat-egory may find that a six month fellowship is enough tohone their surgical skills, whereas those in the second mayfind themselves of the steep part of the learning curve evenat the end of their fellowships. That said, I do not think
applicants should choose their fellowship based on whatthey learned (or did not learn) in residency. Becomingan expert takes many years—indeed, a lifetime of learn-ing.
Approximately half of shoulder and elbow fellowshipsare not based at universities or tertiary care hospitals. Un-like some other fields, perhaps, absolutely top notch edu-cation can be had at a non-university program.
Because shoulder and elbow is a fairly new subspe-cialty—the American Shoulder and Elbow Surgeons or-ganization was founded only 25 years ago—many of thefounders of that Society and the pioneers of the field arestill in active practice. Nevertheless, in recent years therehas been great movement away from programs being iden-tified with particular individuals. This of course does notmean that individuals are not important. The skills andattitudes you acquire in fellowship will be strongly influ-enced by your teachers. Above all, I would value a pro-gram where the teachers emphasize critical thinking,healthy skepticism of common knowledge, and willing-ness to ask and make a strong effort to answer questionsthrough clinical and or basic science investigation.
Clinical Orthopaedicsand Related Research242 Iannotti
Pacific Heights Surgery Center of San FranciscoAttention: Emilie Murphy3000 California Street, 3rd FloorSan Francisco, CA 94115(415) [email protected] Clay Street, #510San Francisco, CA 94115(415) [email protected]
The New York Orthopaedic HospitalColumbia University Medical Center622 West 168th Street, PH11-1130New York, NY 10032(212) [email protected]
NYU-Hospital for Joint Diseases301 East 17th Street, Room 1402New York, NY 10003(212) 598-6509randie.godette.nyumc.org
Presbyterian Medical Center1 Cupp Pavilion, 39th and Market StreetsPhiladelphia, PA 19104(215) [email protected]
Nottingham City Hospital NHS TrustNottingham Shoulder and Elbow UnitHucknall RoadNottingham, NG5 1PBUnited [email protected]
Florida Orthopaedic InstituteAttention: Dawne Philip13020 N. Telecom ParkwayTemple Terrace, FL 33637(813) [email protected]
St. George HospitalDepartment of Orthopaedic SurgeryLevel 2, 4-10 South StreetKogarah, Sydney 2217 NSWAustralia61-2-9350 [email protected]
Mount Sinai Medical Center5 East 98th StreetNew York, NY 10029(212) [email protected]
Mayo ClinicDepartment of Orthopedic Surgery200 First Street SWRochester, MN 55905(507) [email protected]
Department of Orthopaedic Surgery,Washington University
Shoulder and Elbow Fellowship, CampusBox 8233
660 S. EuclidSt. Louis, MO 63110(314) [email protected]
The San Antonio Orthopaedic Group400 Concord Plaza, Suite 300San Antonio, TX 78216(210) [email protected]
Cleveland Clinic Foundation9500 Euclid Avenue A-41Cleveland, OH 44195(216) [email protected]
W.B. Carrell Memorial ClinicShoulder and Elbow Service9301 North Central Expressway, Suite 400Dallas, TX 75231(214) [email protected]
Thomas Jefferson University HospitalDepartment of Orthopaedic Surgery1015 Chestnut Street, Suite 719Philadelphia, PA 19107(215) [email protected]
Beth Israel Medical Center10 Union Square East, Suite 3MNew York, NY 10003(212) [email protected]
University of Washington Medical CenterDepartment of Orthopaedics and Sports
Medicine1959 NE Pacific Street, Box 356500Seattle, WA 98195-6500(206) [email protected]
Massachusetts General and Brigham andWomen’s Hospitals
55 Fruit Street, YAW 3200, Suite 3-GBoston, MA 02114(617) [email protected] Website:
www.shoulderfellow.com
Sports, Orthopedics & Spine569 Skyline Drive, Suite 100Jackson, TN 38301(731) [email protected]
Fondren Orthopedic Group7401 S. Main StreetHouston, TX 77030-4509(713) 799-2300, ext. [email protected]
Copyright © American Academy of Orthopaedic Surgeons 2006. Reproduced here courtesy of Stryker, the exclusive licensee.
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