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Resident Fall 2015 PEDIATRIC ORTH op A E D I C S O C I E T Y O F N O R T H A MERICA’ S Fall 2015 ResidentReview Cutting Edge Orthopaedic Information Enhancing Resident Education From the Editor Kristan A. Pierz, MD Welcome to the Fall 2015 issue of Resident Review – a publication designed to educate and inform residents about the field of pediatric orthopaedics. Contributors to this edition are all members of the Pediatric Orthopaedic Society of North America (POSNA). In this edition, we focus on the spine. In addition to providing a questions and answers section on spine-related topics, we have also included a “Top Picks” annotated reference list. We realize that with so many articles out there, it’s hard to focus your reading. Sometimes you just want to know what the experts think is worth your while, so we’ve included some of our favorite references. Hopefully, you’ll find the articles interesting and informative Kristan A. Pierz, MD Also in this edition, you will find Dr. Pooya Hosseinzadeh’s interview with Dr. Wudbhav Sankar about the fellowship accreditation process. Trying to find the perfect fellowship match can seem like a daunting process. Sifting through lists of programs only to find out that some are and others aren’t “accredited” can be very confusing. Hopefully, this piece will provide you with a better understanding of the process. The world of pediatric orthopaedics is constantly changing, and training needs to keep up with these changes. To help provide some perspective on the field of pediatric orthopaedics, we have included Dr. Jamie Denning’s interview with Dr. Alvin Crawford, recipient of numerous honors including POSNA’s Distinguished Achievement Award and the American Academy of Orthopaedic Surgeons’ Diversity Award. Dr. Crawford has educated numerous students, residents, and fellows at Cincinnati Children’s Hospital, and his leadership and vision have been truly inspirational. Finally, the contributing members of Resident Review would like to take this opportunity to acknowledge and thank Dr. Orrin Franko. Dr. Franko recently completed his residency at the University of California, San Diego. As a resident, he was a frequent contributor to Resident Review, hosting “Technology Corner” and keeping us up to date on lots of exciting apps which he still updates on the website www.TopOrthoApps.com. Although he will be missed, we wish him well in his career and future endeavors. We truly hope that you find this review helpful and informative. In addition to the content presented here, we refer you to past editions available on the POSNA website www.posna.org/Blogs/Resident-Review where you can link to even more articles and study questions. Feel free to share any comments at kpierz@ connecticutchildrens.org. 2015 Editorial Board: Lauren Allen, MD John J. Grayhack, MD Meredith Anne Kristan A. Pierz, MD Saskatoon, SK Canada Chicago, IL Lazar-Antman, MD Hartford, CT Garden City, NY Robert B. Carrigan, MD Christina K. Hardesty, MD Todd F. Ritzmann, MD Philadelphia, PA Cleveland, OH James McCarthy, MD Akron, OH Cincinnati, OH Jamie Rice Denning, MD Pooya Hosseinzadeh, MD Jennifer M. Weiss, MD Cincinnati, OH Miami, FL Kevin M. Neal, MD Los Angeles, CA Jacksonville, FL Steven L. Frick, MD Orlando, FL Update on Fellowship Accreditation: An Interview with Wudbhav Sankar, MD By Pooya Hosseinzadeh, MD The fellowship application process can seem confusing and overwhelming. It’s important to understand your options and try to pick a program that fits your needs. After residency, fellowships offer the opportunity to subspecialize in an area of particular interest. There are numerous training options available, most of which are administrated by the Accreditaton Council for Graduate Medical Education (ACGME); however, there is some variability in the system. Resident Review contributor Dr. Pooya Hooseinzadeh recently interviewed Dr. Wudbhav (Woody) Sankar, Chair, Fellowship Training/Qualification Wudbhav Sankar, MD for Practice Committee, to help clarify some of the issues facing those looking to train in pediatric orthopaedics. Q: In the 2015 Match, the number of unfilled pediatric orthopaedic positions was much higher than in previous Q: We know that some subspecialty fellowships in orthopaedics years. Do you see that as a new trend? are moving towards ACGME accreditation. Could you please let us know where POSNA stands when it comes to A: This past year, all 53 North American applicants fellowship accreditation? matched (100%). In 2014, 54 of 57 applicants from North America (95%) matched. Although this number A: Some subspecialty societies such as the Orthopaedic does vary a bit year to year, there are typically 71 Trauma Association (OTA) have recently developed pediatric orthopaedic fellowship positions offered their own accreditation system out of concerns that across the country. Taken together, the match rate in ACGME was not as relevant to their particular pediatric orthopaedics for North American applicants subspecialty. Because of similar concerns, POSNA is remains quite high, and those occasional applicants considering the development of a POSNA accreditation that do not match most likely would have if they had system. The society is currently working to develop applied to more programs. Because of changes in a framework of what this accreditation system might requirements for ACGME accreditation, however, it has look like and how it could be implemented. This is not become somewhat more difficult for foreign medical necessarily meant to replace ACGME accreditation but graduates to match in ACGME accredited pediatric to offer an alternative for those fellowship programs orthopaedic fellowships. that are not ACGME accredited because they think that system is less relevant and too onerous to pursue. Q: There is concern among some members that in the past 5 years we have trained too many pediatric orthopaedic Q: What efforts have been done in POSNA to address the surgeons which has decreased the number of available accreditation issue? academic jobs. Do you believe that we are training too many A: The POSNA Fellowship Committee and the Board pediatric orthopaedic surgeons? Does POSNA plan to of Directors is actively working on the concept of a address this issue? POSNA accreditation system. A: Opinions on this issue seem to swing back and forth Q: What is your message to future fellowship applicants like a pendulum. I remember a few years back when regarding the accredited and non accredited fellowships? we were concerned as a society that there would be a (Should that play a role in choosing the fellowship?) workforce shortage because of the number of projected A: It should be noted that there is no subspecialty retirements of pediatric orthopaedists. Certainly, we certification in pediatric orthopaedic surgery. Right have seen a swell in fellowship applicants over the now, many programs have voluntarily sought past few years and this has made job searches more accreditation through the ACGME, but many excellent competitive. POSNA closely evaluates workforce fellowship programs have elected not to enter this projections through the practice management voluntary process. One goal of a proposed POSNA commitee. Jeff Sawyer and his committee have finished accreditation system would be to ensure basic a comprehensive analysis of the pediatric orthopaedic standards across all types of pediatric orthopaedic workforce now and for the future. As I understand it, fellowships, but, at this point, I would not advise the need continues for more pediatric orthopaedists in future fellowship applicants to worry too much about many parts of the country, but perhaps not as much for whether or not a fellowship was currently accredited. sub-subspecialists in larger urban settings. 2 Alvin Crawford, MD Interview: Changes in Pediatric Orthopaedics During Your Career Jamie Denning, MD Q: The treatment of what condition do you think has changed most dramatically over your career? How? A: I’ve noticed that things have a way of being cyclical. Though I never set out to be a spine surgeon; I got “backed into it” back before anyone ever carefully looked at an x-ray from the side. Introduction of the sagittal plane brought a new dimension to the spine for surgeons and, fortunately, patients. Scoliosis and spine surgery are both intriguing and challenging to me. The greatest advances have been the concepts of Alvin Crawford, MD rod contouring, segmental fixation and selective site spinal fusion. Those patients undergoing “4 to 4” (T4- but that’s a minor part of the problem. I now realize L4) fusions during my early development may have what the Southwick calculations were trying to tell paid a tremendous price for our education. I’ve seen us years ago. While I haven’t been convinced that and participated in all the iterations of implants from all need a surgical dislocation anatomical reduction, Harrington rods to current segmental stabilization. the Howorth operation equally as big fared well in Routine neuromonitoring is a far-cry longitudinal follow-up, but remains an from the wake-up test and allows Ohio operation. I’m frustrated by early the surgeon to be more creative. “Patients are now onset spine; we haven’t found our way Patients are now up and moving yet. Mehta casting is effective when around much sooner instead of up and moving indicated, but I’ve not been happy with being bedridden/casted/braced for growing rods. The surgical anatomy/ months. It’s amazing and rewarding around much sooner physiology doesn’t work well for for me to live and experience this instead of being sequential surgical intervention. Moving renaissance during my surgical forward, refinement of implantation not career. This is still a work in bedridden/casted/braced requiring repeated interventions and progress and I’ve learned you need development of dependable vertebral a dedicated and at best designated for months.” growth modulation approaches will team to make modern spine surgery better serve this population.
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