I recently read the editorial in the December issue of the Canadian Journal of Surgery (2003; 46: 404–5) and fully agree with all your comments. Current fellowship examinations are antiquated and indeed obsolete in the current environment.
A suggestion I would like to add is to take it one step further: we in teaching centres should come up with a list of the basic set of skills, to be assessed and certified by educators, that all orthopedic residents should have when they finish their residency.
The variety of procedures done nowadays in orthopedic surgery is very broad. It is simply no longer possible that after a 5-year training program, every resident be competent to perform them all. There is enough variability of training that certain residents will have different mixes of skills; these need to be documented by the different training programs. There must be some simple evaluation process that can be put in place so that these individuals can be certified that they know, more than other graduates might, how to do these more subspecialized procedures. Since fulfillment of a secondary postgraduate training fellowship may lead to the acquisition of special skills, some means of recognition of these skills is needed as well.
I think the day is gone that an orthopedic resident passes his or her exams and is qualified for every procedure in Campbell’s [Operative Orthopædics]. This becomes a major problem when young surgeons in their earliest jobs begin applying to do every orthopedic procedure thinkable, even including hemicorpectomies.
Granting privileges to do certain surgical procedures is becoming a complex issue. Here in Hamilton we have tried to break down the different orthopedic procedures into some broad categories, but obviously the system is unperfected. I think we need not only to protect our patients from poorly performed surgery, but also to protect us from ourselves. We sometimes consider ourselves more skilled than we really are.
We in the teaching centres must continue striving to improve surgical education itself, as well as the certification process.