Preparation for Hand Surgery Fellowship: A Comparison of Resident Training Pathways.

Abstract

We read with great interest the article by Drinane et al.1 analyzing the hand surgery case logs of graduating residents from the general surgery, orthopedic surgery, and plastic surgery pathways. We would like to congratulate the authors on an excellent overview of the disparities in experience among the different groups of applicants to hand surgery fellowships. We wish to some offer additional perspective to the authors’ key findings from this study. While case logs of general surgery residents accounted for the majority evaluated in this study (11,189 out of 19,159), it is important to note that general surgery residents represent a small fraction of the total matched hand surgery fellowship applicants. According to data from the 2020 National Resident Matching Program for hand surgery,2 only five out of 175 matched applicants (2.9 percent) came directly from general surgery residencies. These five applicants matched into the one enrolled general surgery–based hand fellowship currently offered.2 This makes us wonder if it is indeed an unwritten clause that general surgery residents interested in hand surgery fellowships need to pursue an independent plastic surgery fellowship first to make themselves competitive for selection to this field. The authors do mention a need for a more standardized hand experience for applicants from different pathways to improve the education of graduating hand surgeons. Is this best achieved by a plastic surgery fellowship following general surgery training, to set up such candidates for success in a 1-year focused fellowship program? Furthermore, while the data for integrated plastic surgery case logs were not publicly available and analyzed, the use of only independent plastic surgery resident case logs limits the determination of the hand surgery experience of graduating plastic surgery residents. Integrated plastic surgery residents pursuing a 6-year residency would possibly accrue greater exposure compared to independent plastic surgery fellows pursuing a 3-year fellowship. Moreover, Bhadkamkar et al.3 demonstrated a strong trend toward the increasing number of positions in the integrated plastic surgery match and a concomitant decrease in independent positions available. From 2007 to 2019, the number of integrated positions has increased from 92 to 172, while the number of independent positions has decreased from 93 to 63.3 General surgery is the most common pathway to an independent plastic surgery residency, but matched applicants to independent plastic surgery programs may have previously completed residencies in neurosurgery, orthopedic surgery, otolaryngology, thoracic and cardiac surgery, or urology.4 Indeed, a candidate progressing from an orthopedic residency to a plastics fellowship would likely have significantly more hand experience. As such, future studies examining the case logs of integrated plastic surgery residents would add immensely to our understanding of the baseline surgical experience of different applicant cohorts. With these data, hand surgery training can be focused and individualized for these groups in order to maximize the value of their 1-year fellowship. As the authors rightly point out, embracing the differences among the three distinct residency pathways is imperative for offering the best education to future hand surgeons. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.