Editorial on residencies and fellowships.

This issue of Spine contains guidelines for spine education in orthopaedic and neurosurgery residencies and spine (surgical) fellowships. They were prepared by the NASS Resident and Fellow Education Committee, chaired by Harry Herkowitz, MD. It should be emphasized that the word guidelines was specifically chosen to avoid the stigmata and controversy associated with accreditation and certification. Though it is unlikely that spine training guidelines will strongly influence the selection of a residency by applicants, they should be useful for fellowship applicants to assess a specific program’s educational and clinical opportunities. Residency training is accredited (accreditation is given to an institution) by the Residency Review Committee (RRC) for a specialty under the overview of the Accreditation Council for Graduate Medical Education (ACGME). As a program chairman and residency director in orthopaedic surgery, I am aware of the focus of this review process. In general, the RRC (in most specialties) evaluates the overall program in terms of balance in all involved disciplines, fulfilling educational expectations through didactic and interactive sessions in general, basic, and clinical science and across regional anatomic areas. Balance should also be achieved between appropriate nonoperative and operative care experience, coupled with a graduated independence in providing care in the residency years. Directors of most specialty divisions within the general training program are expected to provide achievable educational and clinical goals for residents who rotate through their subspecialty. However, these tend to be broad-based and idealistic. The guidelines in this edition of Spine are designed to help program directors of spinal training. That, in general, we are not doing well in this area is demonstrated in a recent article by Dailey and colleagues who assessed “orthopaedic residents perception of the content and adequacy of their residency training.” In general, orthopaedic residents felt their training was good. However, one of the weakest areas was in spine, including “lower back pain management.” This should be of concern since these conditions are so prevalent. It is understandable that many training programs may not have specialists in all subspecialty areas, particularly in spine where it is fragmented into degenerative, deformity, traumatic, etc. If, however, an individual faculty member with broad spine interest is not available, programs should provide the educational needs for the trainees (as listed in the guidelines) through the full-time faculty, or rotations with volunteer, non full-time clinical faculty. Also, with decreasing training spots, as well as finances, and increasing constraints on faculty time, it may be difficult in some institutions to provide a full gamut of spine educational opportunities. Nevertheless, residency program training directors should strive to provide educational and clinical experience in the broad, frequently encountered areas of spine, as listed in the enclosed guidelines. The authors of the guidelines understand that surgical care of spine patients is often diagnostically and technically, as well as medico-legally, challenging. The guidelines do not suggest a resident perform every spinal procedure prior to graduation, but they should be exposed to the more common cases. Even if they are not technically proficient in spine surgery, they should be aware of the indications and requirements for surgery to make appropriate recommendations. Spine fellowships are different than residencies. They are more personal, tend to be one-on-one, and strongly reflect the interest of the fellowship director and colleagues, as well as the fellow. However, despite the institutionally specific nature of each spine program, the overall objectives of the fellowship should be to provide additional advanced training and education in spine care, basic/clinical science, anatomy, patient care, and stimulating new ideas. Much of the knowledge base should be, hopefully, established during the residency. However, that is not always the case. Also, if there is a spine surgery fellowship offered in the same institution, the fellowship and residency directors need to work together to assure there is no compromise of the resident’s experience. The interaction between residents and fellows, when they coexist, is an important one. Fellows should become part of the educational process in a residency program. The fellowship should help fellows become better teachers. Residents should not be allowed to passively defer reading and become surgical assistants if there is a fellow. The program director, as well as the fellows themselves, should help supervise and avoid this from happening. Spine surgery fellowships are different than many other subspecialty training because of the diverse nature of spinal care. Some institutions and/or fellowship directors emphasize degenerative conditions, some concentrate on the lumbar spine; others include or focus on the cervical spine; some strongly emphasize deformity sur-