Is he ready? Are her hands sufficiently dexterous? Is he fluent in the details of this procedure? Such are the questions that veteran surgeons must address when handing responsibility—and surgical drills—to fellows.
Advice From Dr. Bray
Dr. Robert Bray, Founding Director and CEO of Diagnostic and Interventional Spinal Care (D.I.S.C.) in Marina del Rey, California, has had fellows of all talents and characteristics pass through his doors. He says, “Fellows, like fellowships, differ widely. Most of the fellows I work with start out by thinking that they’re ready to do the procedure themselves. They are often frustrated, however, because I start them out very slowly and at first let them do almost nothing. They observe me first, and then I gradually allow them to do pieces of the surgery—first exposure, then drilling, etc.—all based on their competency levels. In general, fellowship mentors differ in how quickly they bring fellows along in the OR.”
So you can’t just hand things off to a fellow, thinking, “Great. That’s one less thing I have to do.” Dr. Bray explains, “What a lot of people don’t know is that it’s actually a lot of work to have a fellow. There are many surgeons who view having fellows as a chance to withdraw themselves from the ‘grunt work’ of things such as labs, putting a chart together, doing a history and physical, surgery prep, and weekend rounds. The problem with this is that many of those things are integral to patient care. I have to know my patient…and the only way I’m going to do that is to have ‘face time’ with them.”
“I am involved in labs, do rounds with the patients, etc. Fellows really need to be observed by a mentor every step of the way. I have seen cases where fellows have been allowed to operate without much supervision—or no supervision—and got into trouble with the nerve linings and screw placement.”
Advocating for staying involved, Dr. Bray says, “Take the old adage that to get a good outcome you need to have the right patient, the right surgery, done right. If you offload a number of responsibilities then how will you know you are hitting these marks? There is a careful decision making process involving patient evaluation and the selection of the appropriate procedure. When the wrong procedure is done it is sometimes because the mentor didn’t put enough time into choosing the right procedure.”
One thing is for sure. Surgeons didn’t become surgeons to have their hands tied behind their backs. Dr. Bray: “There are two types of fellowships, one in which trainees are active and one in which they just observe. You can’t ever completely learn just by observing. At some point before you are ‘let loose’ on the public you should have hands-on experience that is properly supervised. Actually, I am of the opinion that there should be a totally different certificate for those individuals who have done an observational only fellowship.”
A patient may think that because Dr. X has completed a fellowship, he or she is fully trained and competent. Speaking to this issue of quality, Dr. Bray states, “The fact that there is no rating system for fellows is controversial and is something that needs to be worked out. It’s usually a pass/fail designation…and hardly anyone is designated as failing. When someone gets a certificate at the end of the year it doesn’t say that the person is competent or got a high score. I have had frank discussions with some fellows who have completed the fellowship year, but needed more time to master different concepts/procedures. I’ve advised them to do more time somewhere else. Fortunately, they have taken this advice.”
“Where is the umbrella and the measuring stick?” asks Dr. Bray. “At present we have no superstructure that regulates fellowships. Nor do we have any type of ranking of the programs for spine. It seems to go by subspecialty, i.e., for spine surgery there is no approving structure, whereas for sports medicine there is an AAOS approved fellowship. Having oversight and solid guidelines would help ensure high quality training. For example, we need a guideline saying that you must be present at every case your fellow does. And, as the situation is now, any orthopedist or neurosurgeon in private practice can take out an ad saying, ‘I do spine surgery and am accepting fellows.’ Then at the end of the year he or she just prints a certificate off the computer. That is just too random.”
And now to the less tangible, but important topic of vainglory. Even if the fellow who casts his shadow upon your doorstep is short of stature, his ego may be large. “While fellows can and should have a healthy ego, they have to be open to learning new things, ” says Dr. Bray. “On occasion I have a new fellow who wants to show everyone ‘how it’s done, ’ at which point I make it clear that this is not the reason they’re here. Fortunately, with years of experience behind me, I can demonstrate to them there is still a lot to learn. Once the fellow realizes this they usually move forward quickly. It really depends on the individual. I have some people doing a lot by the three month mark, but with others I have to take things more slowly. And yes, for those who have to wait longer, it’s tough on their egos. But they do catch up at some point.”
Dr. Wolf Weighs In
For Dr. Brian R. Wolf, the Director of the Sports Medicine Fellowship at the University of Iowa, “preparation” is the mantra. “First of all, you must thoroughly assess each fellow’s capabilities and knowledge levels. I sit down with the fellows before each case and talk about the plan and how we’ll fix xyz problem should it arise. I go into the OR knowing exactly how hands-on I will be. Having weekly case conferences is also an important part of planning. Reviewing, for example, ‘Here is a shoulder injury and here is what I’m thinking needs to be done. This is what you need to think about from an anatomical viewpoint, from a technical viewpoint and a post operative plan viewpoint.’”
And if the fellow finds himself in dire straights? Dr. Wolf: “Let’s say we’re ready to start arthroscopically fixing a rotator cuff and we’re allowing the fellow to actively participate. He is passing the main sutures, but having some difficulty. The patient’s shoulder is getting more swollen and we need to be finishing up to avoid having prolonged anesthesia time. At that juncture the roles are exchanged and instead of being the fellow’s assistant I become the primary surgeon. Later there is a post-op meeting about what went wrong. During this time I have to help the fellow understand that dragging out the procedure means that suture management and repair gets more difficult the longer the case goes on. Plus, there is a risk that the patient’s hospital or recovery room stay will be lengthened when you have a longer anesthesia time.”
For a fellow who is struggling, the most important thing, says Dr. Wolf, is that you don’t set him or her up for further failure. “If necessary, we need to provide fellows with avenues other than the operating room suite to improve their skills. For example, we have an arthroscopy and surgery teaching lab where they have access to cadaveric specimens. Our fellows are scheduled to spend time in the learning lab every week working on surgical skills and approaches. This is a great setting for getting more familiar with new instruments and practice procedures in a low pressure environment. If we identify some deficient skills for a particular fellow we will have them spend extra time working on things in the training lab.”
While it’s informative to talk to fellows, it’s even better, says Dr. Wolf, to closely watch their actions when you first begin working with them. “Some fellows talk a big game but when it comes time to display their knowledge, they have not yet mastered the skill. At the same time there are always silent superstars out there who don’t say too much, but are highly talented. The only way to get a grasp on what exactly they can do is to watch them closely.”
“Every fellow has basic things that he or she has learned in residency…and all cases have simple and complex aspects. This means that you can gauge their skill levels right away, early in the fellowship year, no matter what they tell you. I will ask them, ‘Have you seen or done this in residency, learned about this in the lab, or read about it?’ Within 5 minutes of them participating in the simple parts of the case I can get a good idea of their talent/skill level. That then also plays into how much involvement they’ll have in the more challenging parts of a case. This evaluation continues throughout the fellowship training year, and as the fellow masters more skills he or she becomes more involved.”
At certain times, says Dr. Wolf, observation has its place. “I’ve come to the conclusion that if you’re a good learner then you can learn by watching—your hands don’t necessarily have to be active in the case. Observation would be appropriate when fellows are seeing a technique or procedure for the first time. Then as they become familiar with the skills and techniques needed they gradually are involved more actively in cases as the fellowship year proceeds.”
As for any formal assessment of trainees, Dr. Wolf calls upon images emanating from the Middle Ages: “Medicine and surgery remain bound to the tradition of apprenticeships. A more structured way of determining fellows’ readiness for the world is likely coming down the pike, but as of yet there is no surgical skill test to pass other than their mentors’ subjective assessment. The onus is on the educators to ensure that their protégés are truly prepared to undertake high level surgery. Orthopedic surgery and neurosurgery are two of the most highly sought after fields for medical students, so I do feel that we’re getting the best and brightest.”
In the end, it’s up to the student to find the right mentor, and it’s up to the mentor to take full responsibility for his or her apprentice. And, it’s the mentor who should be doing most of the observing…of the fellow.
