"Spinal surgery and spinal surgeons come from either orthopedic surgery or neurological training background, but they focus their practice only on spinal procedures," said Lawrence Lenke, MD, Chief of Spinal Surgery at Washington University School of Medicine in St. Louis and Jerome J. Gilden Distinguished Professor of Orthopedic Surgery and Professor of Neurological Surgery, in a Becker's Spine Review report. "It's becoming a subspecialty of medicine and surgery of its own. It's been a long evolutionary process, but ultimately I think we are going to see spinal surgery as its own discipline, instead of surgeons dabbling in spine part-time."
Some surgeons are undergoing two fellowships — one in orthopedic spine and another in neurospine — while still others subspecialize even further to categories such as spinal deformity, cervical spine or minimally invasive techniques. There are some programs at large medical centers, such as Washington University or Cleveland Clinic, that include cross-pollination between fellows in both departments.
"Spine is becoming so complex that a fellowship might not be just one year in the future," said Richard Guyer, MD, Co-Founder of Texas Back Institute, Director of the Spine Fellowship Program and Chairman of the Board for the Texas Back Institute Research Foundation in Becker's Spine Review report. "We give a broad fellowship, but one could spend an entire year focused on just minimally invasive or deformity training. We may see a change in the whole educational process, shortening the residency programs to add another year to fellowships, because we are seeing more residents who know they want to focus on spine during their second or third years."
According to some projections, by 2020 among the groups with the largest influx of patients will be orthopedics and ophthalmology. A physician shortage of 130,000 is expected by 2025 according to projections from the Association of American Medical Colleges, which will have a serious impact on patient access to care.
Many professional societies are supporting two legislative acts to increase the number of medical students able to train in orthopedics and spine over the next few years. HR1180, the "Resident Physician Shortage Reduction Act" and HR 1201, the "Training Tomorrow's Doctors Today Act," were brought in front of the House of Representatives and are designed to increase the number of graduate medical education spots, creating 15,000 more residency positions, over the next five years.
However, as the spine specialty becomes more complex some feel fellowship hours will become a bigger focus.
"I think it would make more sense to extend the fellowship time, but it would take a while for residency programs to come to that conclusion," said Dr. Guyer. "Spine surgery is becoming more complex and techniques are changing quickly, so I think this is a field that will continue to flourish."
In addition to traditional fellowships at academic medical centers, more private practices are now offering fellowships for spine surgeons. Texas Back Institute, SpineCare Medical Group, Twin Cities Spine, Deuk Spine Institute and San Francisco Spine Center all have established fellowship programs. Fellows are able to engage in the clinical aspect of the practice as well as learn about how private practice works. However, there are also downsides to the relationship between mentor/mentee during spine surgeon training.
"Certainly later in training a physician that is leaving their mentor could be seen as a potential competitor or partner in certain situations," says Amir Vokshoor, MD, a neurological spine surgeon with DISC Sports & Spine in Marina Del Rey, Calif., in a Becker's Spine Review report. "It's a delicate dance that has been traversed well in some scenarios and not in others. I think honestly, transparency and respect are the cornerstones to trying to make the transition as seamless and cordial as possible."
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