The first years after spine fellowship do not always come with a gentle learning curve.
A young surgeon may expect to start with straightforward cases and gradually take on more difficult ones. The reality, Megan Johnson, MD, said, can look very different.
Depending on the practice, established partners may already be handling the routine cases. The newest surgeon can instead find themselves facing neuromuscular deformities, revisions and other complex cases earlier than expected.
That possibility shapes how Dr. Johnson thinks about preparing the next generation.
As program director of the Dorothy & Bryant Edwards Fellowship in Pediatric Orthopedics and Scoliosis at Dallas-based Scottish Rite for Children, she is responsible for helping fellows make the transition from supervised training to independent practice. She is also a pediatric orthopedic surgeon and associate professor of orthopedic surgery at UT Southwestern Medical Center in Dallas.
Her view of what young spine surgeons need reflects a growing tension in surgical education: Technology is advancing rapidly, but there are parts of becoming a surgeon that cannot be automated or accelerated.
“You need to be in the operating room getting reps in, and you need to be doing a substantial portion of the case,” Dr. Johnson told Becker’s.
When the hard cases come early
High case volume does not necessarily mean broad preparation. A fellow may leave training comfortable with idiopathic scoliosis but have had far fewer opportunities to participate in the complex cases that can arrive early in independent practice.
“It’s one thing to do a ton of idiopathic scoliosis during fellowship,” Dr. Johnson said. “But it’s really being able to see the harder, more complex things that can help prepare you.”
Those opportunities are not always easy to provide. Teaching competes with the other demands on attending physicians, and some of the most difficult procedures are uncommon even at academic centers.
Dr. Johnson encourages early-career surgeons who did not get enough exposure during fellowship to actively seek it afterward. That can mean joining partners on difficult cases, working with a neurosurgeon, visiting surgeons elsewhere in the country or gaining experience through courses and cadaver labs.
“There are ways to get reps in, even if they’re not your own patients,” she said.
For especially complex procedures, however, observation can only go so far. Dr. Johnson pointed to three-column osteotomies, including vertebral column resections, as an example. Fellows may participate in portions of these operations without performing an entire case themselves, and the technical demands extend beyond the resection to managing the reduction, spinal cord and neuromonitoring.
“You’re just not going to get any of that completely by watching,” she said.
Even cadaver training has limits. Practicing without a functioning spinal cord is fundamentally different from performing the operation on a patient. “It’s a whole other ball game,” Dr. Johnson said.
The surgeon behind the robot
That training challenge is becoming more complicated as navigation and robotics become increasingly common in spine surgery. Dr. Johnson considers enabling technology part of the field’s future. She also worries about surgeons becoming dependent on it before mastering the fundamentals underneath it.
“The robot or navigation is really only as good as the surgeon using the technology,” she said. “If you’re a bad surgeon, those enabling technologies aren’t going to make you better. If you’re already a great surgeon, they’ll make you even better.”
For pedicle screw placement, she said, surgeons still need foundational skills that allow them to interpret navigation correctly, recognize when something has gone wrong and operate if the technology is unavailable.
“If you show up and the robot or the navigation’s not working, you need to know how to do the case without it,” Dr. Johnson said.
She sees value in training environments where fellows encounter multiple approaches, freehand techniques, fluoroscopy, navigation and robotics, rather than learning only one way to operate.
That balance may become more difficult to preserve.
“My generation of surgeons didn’t have that, so we all learned how to put screws in by hand,” Dr. Johnson said. “As we go into the future, there may be a time when spine surgeons have never put in a pedicle screw by hand. To me, that’s a little bit scary.”
That does not mean resisting technology. Dr. Johnson said surgeons have to evolve with the field and become comfortable incorporating new tools. But she believes the fundamentals should come first.
The harder skill to teach
Technical proficiency is only part of what Dr. Johnson wants fellows to carry into independent practice. The harder skill may be knowing their own limits.
When considering a complex deformity case, she said, the question is not simply whether a surgeon can technically perform the operation. Surgeons also have to consider whether they, and the hospital around them, are equipped to manage everything that could follow.
“Maybe you can accomplish the surgery, but if there is a complication, is your hospital going to be equipped to handle it?” she said. “Is there somebody who can bail you out if you’re having trouble? Is there another co-surgeon who you could work with?”
For Dr. Johnson, practicing independently does not mean practicing in isolation. Some complex cases may appear only once a year in an average practice, making it important to recognize when to seek another opinion, bring in a co-surgeon or refer the case to someone who performs the procedure more routinely.
“Asking for help or asking questions is not a sign of weakness,” she said. “It has nothing to do with your competence or your abilities as a surgeon.”
That judgment requires something harder to teach than a surgical technique.
“A lot of it is just being humble, knowing your own limitations and realizing what you can and cannot take on safely,” Dr. Johnson said.
The decision before the OR
If Dr. Johnson could design the ideal fellowship, it would be high volume and expose surgeons to a wide range of spine pathology, implant systems and approaches.
But one of its biggest priorities would happen before anyone enters the operating room: teaching indications. Dr. Johnson sees patients for second and third opinions and revisions. In some of those cases, she said, the problem traces back not to how an operation was performed, but to the decision to operate in the first place.
“Often, not having the ability to say, ‘I’m not going to operate on that,’ is what gets people in trouble,” she said.
That distinction is especially important in pediatric spine surgery. A radiograph may show a deformity, but Dr. Johnson cautions against allowing the image itself to become the reason for an operation.
“Yes, there’s an X-ray, but there’s also a patient attached to the X-ray,” she said. “It’s about treating the patient. It’s not about treating every little spine deformity you see on an X-ray.”
For children, the calculation is further complicated by growth, which can affect the results of spine surgery and the techniques available. Dr. Johnson said that requires an additional critical lens when deciding whether to operate.
She also believes surgeons have sometimes been too quick to intervene on conditions that could have waited or may not have required surgery. Once that decision is made, it can be difficult to reverse course.
“You’ve set the patient down a pathway that it’s hard for them to get off of,” Dr. Johnson said.
The next generation of spine surgeons will have increasingly sophisticated tools for operating. For Dr. Johnson, the lesson fellowship has the most trouble teaching is not how to use them, but how to decide whether an operation is needed in the first place.
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