Hand Surgery Fellowship Research Articles

Social Media Use Among Academic Hand Surgeons

PURPOSE: Social media has revolutionized communication in society and has become an important interface between patients, trainees, and physicians for education, networking, and marketing. A growing number of surgeons are embracing this trend by increasing their social media presence. Many studies have investigated the benefits of a surgeon’s web presence in plastic and aesthetic surgery, but a paucity of data exists in use among academic hand surgeons. The objective of this study was to evaluate social media use in fellowship trained, academic hand surgeons and to investigate differences between orthopaedic and plastic surgery trained hand surgeons. METHODS: Hand surgery fellowship programs were identified from the ASSH website, and a list of faculty members from each respective program was compiled. A search was performed for faculty members on social media platforms including Facebook, Instagram, Twitter, LinkedIn, and personal websites. The respective accounts and/or personal websites were investigated for any content related to hand surgery; accounts with personal content only were not included. Faculty members were analyzed by sex, board certification status, subspecialty of residency training (plastic surgery versus orthopaedic surgery), years in practice, geographical region (east, west, south, or midwest), and professional presence on a personal website or accessible social media platform. Analysis of variance and student t tests were performed to evaluate the statistical significance (P = 0.05) of differences between groups. RESULTS: A total of 469 academic hand surgeons were included. Among academic hand surgeons in the United States, LinkedIn is the most common platform utilized at 40.3%, followed by Facebook (15.78%), a personal website (13.86%), Twitter (12.37%), and Instagram (4.05%). Plastic hand surgeons are more present on Instagram (8.26% versus 2.59%) and Twitter (19.01% versus 10.06%) (P = 0.0062837 and P = 0.009921, respectively). Male hand surgeons were more likely than female hand surgeons to use LinkedIn (41.19% versus 34.85%) (P = 0.044956). Southern (18.89%) and eastern region (14.36%) surgeons utilized personal websites more than western (6.52%) and midwestern (4.60%) surgeons (P = 0.0319107). CONCLUSION: Despite the widely known use of social media amongst plastic and aesthetic surgeons, this study shows the use of web-based marketing strategies to be quite rare in the academic hand surgery setting. Social media can have a profound impact on medical practices and thus we suggest that academic plastic and orthopaedic hand surgeons throughout the United States should consider having a larger social media presence to expand advertising, improve patient education, and enhance networking within their practices.

Medicare Compensation Rates for Hand and Shoulder/Elbow Surgery by Operative Time: A Comparative Analysis.

There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional "marketability" in a subspecialty they perceive as having higher compensation. Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery. Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P<0.01). Non-weighted mean wRVUs/min were similar (0.12±0.03 vs. 0.13±0.03, P = 0.12). When weighted by procedure frequency, hand surgery had greater wRVUs/min (0.15±0.036 vs. 0.13±0.032), payments/min ($14.17±4.50 vs. $6.97±2.26), charges/min ($75.68±30.47 vs. $42.61±7.83), and reimbursement (20±5.0% vs. 17±6.0%) (all, P<0.01). According to Medicare compensation, and when weighted by procedure frequency, hand procedures are associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared with shoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensation is complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set as opposed to primarily monetary reason.

A Bibliometric Analysis of Research Productivity During Residency for 125 Hand Surgery Fellows

Research output is 1 element of a multifactorial process that fellowships consider when evaluating applicants. Hand fellowships present a unique circumstance in which applicants from various specialties-plastic surgery, orthopedic surgery, or general surgery-may apply. This project aims to assess and compare the research output among current hand surgery fellows who received their residency training in plastic surgery vs. orthopedic surgery. This project was a cross-sectional study of current hand surgery fellows for the 2018-2019 academic year affiliated with Accreditation Council for Graduate Medical Education-accredited hand surgery fellowship programs in the United States. Fellows were identified using departmental websites, and their bibliometric profiles were found on SCOPUS. The study variables collected were bibliometric (total number of publications, total number of citations, total number of first-author publications, maximum number of citations for a single work, h-index) and demographic (gender, training background). Descriptive analyses were performed as well as logistic regressions. According to National Resident Matching Program, 170 applicants successfully matched to hand surgery fellowships for the 2018 appointment year. A total of 125 (74%) hand surgery fellows were identified across 83 programs. Thirty-five fellows (28%) received their residency training in plastic surgery, 85 in orthopedic surgery (68%), and 5 in general surgery (4%). Fellows published a total of 436 peer-reviewed publications. Bibliometric measures of total number of publications, total citations, maximum citations for a single work, and h-index were significantly higher among fellows with a plastic surgery background than those with an orthopedic surgery background. Total publications, total citations, maximum citations, and h-index remained significant when controlling for gender and residency affiliation (academic vs. community). The majority of current hand fellows attended orthopedic residencies. However, fellows from plastic surgery residencies have higher research productivity than their orthopedic surgery counterparts.

Corrigendum: Longitudinal Microsurgery Laboratory Training during Hand Surgery Fellowship

Corrigendum: Longitudinal Microsurgery Laboratory Training during Hand Surgery Fellowship

Longitudinal Microsurgery Laboratory Training during Hand Surgery Fellowship.

Laboratory training courses have traditionally offered an attractive method to learn microsurgery in a low-risk environment. However, courses are often limited by cost, accessibility, and their one-time, nonlongitudinal nature. Our aims were to (1) describe our institution's microsurgical training course for hand surgery fellows, which is longitudinal and integrated within our fellowship curriculum and (2) investigate how this course affects the microsurgical confidence and competence of trainees throughout their fellowship year. All hand fellows who trained in our 1-year combined hand surgery fellowship from 2016 through 2018 participated in this study. Baseline data on the type and duration of residency training, previous microsurgery experience and self-reported confidence, knowledge, and interest in microsurgery were recorded. Self-reported scores were documented using a continuous scale ranging from 0 to 10. An initial 3-day laboratory course combining the use of didactic teaching, a nonliving synthetic model, and a live rat model was conducted. Repeat laboratory training occurred thereafter at 6 and 12 months. At the end of each session, fellows repeated the baseline questionnaire and faculty assessed their microsurgical competence using a standardized global rating scale (GRS). A total of six fellows (2 years) were enrolled. At the end of the initial course, there was a statistically significant increase in mean self-reported confidence in microsurgery from 4.3 to 6.2 and knowledge from 4.7 to 6.5. Mean scores in interest were unchanged, from 9.2 to 9.3. There was also an increase in mean GRS score from day 3 to months 6 and 12. A longitudinal microsurgical training course integrated within a hand surgery fellowship is associated with increased confidence and microsurgical skill. This study describes our approach and its feasibility.

Evaluation of the Acquisition of Ultrasound Proficiency in Hand Surgery Fellows.

To evaluate hand surgery fellow ultrasound (US) evaluations and performance of clinically relevant tasks after brief instruction. Six hand surgery fellows completed an US assessment and a survey on US use before and 1 month after a 30-minute US course. The time to obtain an adequate image decreased from 4 minutes 42 seconds (4:42; range, 3:57-7:55) to 0:52 (range, 0:30-1:14; P < .001). Participants' performance for structure identification improved from 9.7 (range, 8-13) to 12 (range, 10-13) of 14 structures (P < .05). The average time to completion decreased from 14:6 (range, 12:08-18:30) to 9:34 (range, 4:40-15:54; P < .01). After instruction, all 6 participants identified and measured the cross-sectional area of the median nerve, identified and measured a zone 3 flexor tendon gap, and identified a simulated flexor digitorum profundus avulsion and its level of retraction (P < .05). Five of 6 successfully administered an US-guided injection to the extensor carpi ulnaris subsheath. After a 30-minute instructional session, hand surgery fellows can achieve a basic level of US competency.

Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship-trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, "How soon after your carpal tunnel surgery did you notice an improvement in your sleep?" Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

The Black Cloud Phenomenon in Hand Surgery.

Background: The term black cloud for a surgeon is generally used to describe someone who is unusually busy compared with his or her counterparts, and it is a superstition that tends to pervade the medical world. The purpose of this study is to investigate whether black clouds exist in hand surgery. Methods: We examined one academic year's worth of hand surgery-specific call at a level I trauma center and tabulated the number of hand-related patient transfers and add-on cases per surgeon. Each surgeon was given a black cloud rating by the fellows who were in training that year. Correlations were made between the black cloud rating and the surgeons' call volume. Results: There were 12 surgeons who shared 365 days of hand call, and 5 of them are hand surgery fellowship trained. Those 5 surgeons tended to be busier on their call days, with more cases added on overnight and the next day, and also had worse black cloud ratings than the 7 non-hand fellowship trained surgeons. Conclusions: In regard to hand surgery, while true emergencies occur and require emergent intervention, how busy hand surgeons may be during call may be influenced by a variety of factors not related to their patients' problems but rather their daily schedules, their hospitals' ability to facilitate add-on cases, and their rapport with their fellow surgeons to share case loads.

The Impact of Specialty on Cases Performed During Hand Surgery Fellowship Training

Hand surgery fellowship programs in the United States are predominately sponsored by departments or divisions of orthopaedic surgery or plastic surgery. This study compares the operative experiences of hand surgery fellows graduating from orthopaedic or plastic surgery hand surgery fellowships. Operative case logs of 3 cohorts of hand surgery fellows graduating during the academic years of 2012-2013, 2013-2014, and 2014-2015 were analyzed. The median case volumes were compared by specialty via Mann-Whitney U tests. An arbitrary 1,000% change between the 90th and 10th percentiles of fellows was used as a threshold to highlight case categories with substantial variability. In this study, 413 orthopaedic hand surgery fellows (87%) and 62 plastic surgery hand surgery fellows (13%) were included. Plastic surgery fellows reported more cases in the following categories: wound closure with graft; wound reconstruction with flap; vascular repair, reconstruction, replantation, or microvascular; closed treatment of fracture or dislocation; nerve injury; and congenital (p < 0.05). Orthopaedic surgery fellows reported more cases in the following categories: wound irrigation and debridement fasciotomy or wound preparation; hand reconstruction or releases; wrist reconstruction, releases, or arthrodesis; forearm, elbow, or shoulder reconstruction or releases; hand fractures, dislocation, or ligament injury; wrist fractures or dislocations; forearm and proximal fractures or dislocations; miscellaneous insertion or removal of devices; shoulder arthroscopy, elbow arthroscopy, and wrist arthroscopy; decompression of tendon sheath, synovectomy, or ganglions; nerve decompression; Dupuytren; and tumor or osteomyelitis (p < 0.05). Plastic surgery fellows reported substantial variability for 12 case categories (range, 1,024% to 2,880%). Orthopaedic surgery fellows reported substantial variability for 9 case categories (range, 1,110% to 9,700%). Orthopaedic and plastic hand surgery fellowships afford disparate operative experiences. Understanding these differences may help to align prospective trainees with future career goals and to guide discussions to better standardize hand surgery training.

Second Commentary on "Partial Wrist Denervation: The Evidence Behind a Small Fix for Big Problems".

Second Commentary on "Partial Wrist Denervation: The Evidence Behind a Small Fix for Big Problems".

Analysis of National Institutes of Health Funding in Hand Surgery.

Background: Federal research dollars help investigators develop biomedical therapies for human diseases. Currently, the state of funding in hand surgery is poorly understood. This study defines the portfolio of National Institutes of Health (NIH) grants awarded in hand surgery. Methods: This was a cross-sectional study of hand surgeons in the US. Faculty members of accredited hand surgery fellowships and/or members of the American Society for Surgery of the Hand were queried in the NIH RePORT database for awards obtained during 2005-2015. Results: Of 2317 hand surgeons queried, only 18 obtained an NIH grant (0.8%). Thirty-eight unique grants were identified totaling $42 197 375. R01 awards comprised the majority of funding (78.0%) while K08 awards accounted for 1.1%. The K-to-R transition rate was zero. The National Institute of Arthritis and Musculoskeletal and Skin Disease supported the most funding (65.2%), followed by the National Institute of Neurological Disorders and Stroke (30.8%). There was no statistically significant difference in NIH funding totals with hand surgeon characteristics. Funding supported translational (46.0%), basic science (29.6%), clinical (21.0%), and education-based (3.4%) research. Peripheral nerve (33.3%) and bone and joint disease (30.1%) received the most research funding. Conclusions: Less than 1% of hand surgeons obtain NIH research grants. Of the 2 identified K08 awards, none led to a subsequent R award. Future research should identify barriers to grant procurement to design effective policies to increase NIH funding in hand surgery.

The Effect of Skin Pigmentation on Determination of Limb Ischemia.

Timely identification of tissue ischemia is critical, both in the traumatized limb and following free tissue transfer. The purpose of this study was to determine if skin pigmentation affects the ability to detect limb ischemia. We conducted a study of healthy controls exposed to limb ischemia. The subjects were classified based on skin pigmentation using a defined skin type assessment tool, a visual color scale, and self-description of race. Participants were randomized by limb and tourniquet status; surgeons were blinded to both. Ischemia was induced by tourniquet insufflations, and board-certified orthopedic and plastic surgeons who had completed an accredited hand surgery fellowship conducted physical examinations. The surgeons monitored the forearms at 2, 6, and 10 minutes based on appearance of ischemia, capillary refill, and color in 3 locations on the limbs (posterior interosseous artery flap skin territory, radial forearm flap skin territory, and the digits). We found a significant decrease in the ability to detect ischemia in participants with increased skin pigmentation, as documented by all metrics, when evaluating the posterior interosseous artery and radial forearm flap skin territories at all time points. For example, when monitoring the posterior interosseous artery flap with the tourniquet insufflated at time 10 minutes, 92.9% of Caucasians were correctly identified as being ischemic whereas only 23.3% of African Americans were correctly identified. Skin pigmentation significantly affects the identification of an ischemic limb/skin flaps on physical examination. Whereas the standard treatment for monitoring of free tissuetransfer is clinical examination, that may not be sufficient for patients with increased skin pigmentation. Surgeons should exercise particular vigilance during physical examination of a potentially ischemic limb/skin flaps with greater skin pigmentation. Diagnostic II.

Hand Surgery Fellowship Selection Criteria: A National Fellowship Director Survey.

BackgroundCandidate characteristics for hand surgery fellowship training remains unknown, as very little data is available in the literature. This study aims to provide information on the criteria that are employed to select candidates for the hand surgery fellowship match.MethodsA 38-question survey was sent in April 2015 to all Accreditation Council for Graduate Medical Education recognized hand surgery fellowship program directors (n=81) involved in the U.S. match. The survey investigated factors used for the selection of applicants, including medical school, residency training, research experience, fellowship interview, and candidate characteristics. A 5-point Likert scale was used to grade 33 factors from “not at all important” (1) to “essential in making my decision” (5); or for five controversial factors from “very negative impact” (1) to “very positive impact in making my decision” (5).ResultsA total of 52% (42 out of 81) of responses were received from hand surgery fellowship program directors. The most important influential factors were interactions with faculty during interview and visit (4.6±0.6), interpersonal skills (4.6±0.5), overall interview performance in the selection process (4.6±0.6), professionalism and ethics (4.6±0.7), and letters of recommendation from hand surgeons (4.5±0.7). Factors that have a negative impact on the selection process include visa requirement (2.1±1.2), graduate of non-plastic surgery residency program (2.4±1.3), and graduate of a foreign medical school (2.4±1.1).ConclusionsThis study provides data on hand surgery fellowship directors’ perception on the criteria important for fellowship applicant selection, and showed that interview-related criteria and letters of recommendation are the important factors.

Differences in the Treatment of Distal Radius Fractures by Hand Fellowship Trained Surgeons: A Study of ABOS Candidate Data

The management of distal radius fractures differs based on the nature of the fracture and the experience of the surgeon. We hypothesized that patients requiring surgical intervention would undergo different procedures when in the care of a surgeon with subspecialty training in hand surgery as compared with surgeons with no subspecialty training in hand surgery. We queried the ABOS database for case log information submitted for part II of the ABOS examination. Queries for all codes involved with distal radius fracture management were combined with associated codes for the management of median nerve neuropathy, triangular fibrocartilage complex tears, ulnar shaft, and styloid fractures. Hand fellowship trained orthopedic surgeons were compared with those completing other fellowships and non-fellowship trained orthopedic surgeons during their board collection period. During the study period, 2,317 orthopedic surgeons reported treatment of 15,433 distal radius fractures. Of these surgeons, 411 had hand fellowship training. On a per surgeon basis, fellowship trained hand surgeons operatively treated more multifragment intra-articular distal radius fractures than their non-hand fellowship trained counterparts (5.3 vs 1.2). Additional procedures associated with the management of distal radius fractures were also associated with the fellowship training of the treating surgeon. Among orthopedic surgeons taking part II of the ABOS certifying examination, differences exist in the type, management, and reporting of distal radius fractures among surgeons with different areas of fellowship training. This study describes the association of hand surgery fellowship training on the choice of intervention for distal radius fractures and associated conditions.

Side-to-Side Versus Pulvertaft Extensor Tenorrhaphy—A Biomechanical Study

We hypothesized that a side-to-side (STS) tendon repair has biomechanical characteristics that match those of a Pulvertaft (PT) weave. Thirty extensor tendons were harvested (4 extensor digitorum communis and 1 extensor indicis proprius from 6 cadaver arms). Three hand surgery fellows with similar backgrounds of training under the same conditions and precise standardized technique performed the repairs (5 PT and 5 STS per surgeon). After the repairs, the tendons were passed through a graft-sizing guide to determine bulk and results were expressed as a repaired versus native diameter ratio. The specimens were then tested for ultimate strength and fatigue properties. Failure type and mechanical properties were recorded and compared with those of the native tendon. The average peak force to failure was 93 ± 20 N for the STS and 62 ± 32 N for PT group. Relative strength ratio (repair strength compared with native tendon strength) was 37% ± 21% for the STS and 22% ± 11% for the PT group. In the STS group, all failures occurred as a result of tissue failure; however, in the PT, suture failures occurred in 3 tendons before tissue failure. The mean bulk ratio of the repaired site versus native proximal tendon was 37 ± 14% and 40%±22% more for the STS and PT groups, respectively. These values for native distal tendon were 28% ± 9.9% and 26% ±24 %, respectively for STS and PT repair. Furthermore, the bulk of the repaired site for the STS and PT groups was 4.2 ± 0.50 and 4.7 ± 1.2 mm, respectively. Side-to-side repair technique showed superior biomechanical properties while demonstrating comparable repair bulk of the tendon coaptation compared with the Pulvertaft weave. The results of this study may help guide a surgeon's choice of repair techniquewhen addressing tendon injuries or tendon transfers.

Assessment of the Accuracy of Online Information Regarding Trigger Finger.

Review of the recent literature suggests substantial use of the Internet by patients seeking health care information despite questionable accuracy and readability of information presented on some websites. The purpose of our study was to assess the accuracy, quality, and readability of online information regarding trigger finger. Three terms ("trigger finger", "stenosing tenosynovitis", and "finger locking") were used to query three Internet search engines to evaluate websites regarding information about trigger finger. Three hand surgery fellows independently assessed website accuracy and quality using standardized scoring criteria. The Fleisch-Kincaid reading grade level score was used to assess website readability. Website authorship and commercial association were also noted. Sixty-nine unique websites were assessed. Internet information obtained using the search term "stenosing tenosynovitis" was written at a significantly higher reading level than information found using "finger locking" or "trigger finger". Website quality and accuracy were both significantly better in websites authored by physicians compared to websites authored by non-physicians. However, website accuracy was significantly poorer in websites featuring commercial association. Additionally, websites presenting information written below the 8(th) grade reading level demonstrated poorer accuracy. Search term has a significant effect on the readability of online information regarding trigger finger. Despite the terminology used in searches, most websites are largely inaccurate and may not be easily understandable by the general population. This demonstrates a substantial barrier to accessing accurate health care information and may impact patient outcomes. Hand surgeons should direct patients towards websites presenting accurate information with easily readable content.

Hand Society and Matching Program Web Sites Provide Poor Access to Information Regarding Hand Surgery Fellowship.

The Internet is a common resource for applicants of hand surgery fellowships, however, the quality and accessibility of fellowship online information is unknown. The objectives of this study were to evaluate the accessibility of hand surgery fellowship Web sites and to assess the quality of information provided via program Web sites. Hand fellowship Web site accessibility was evaluated by reviewing the American Society for Surgery of the Hand (ASSH) on November 16, 2014 and the National Resident Matching Program (NRMP) fellowship directories on February 12, 2015, and performing an independent Google search on November 25, 2014. Accessible Web sites were then assessed for quality of the presented information. A total of 81 programs were identified with the ASSH directory featuring direct links to 32% of program Web sites and the NRMP directory directly linking to 0%. A Google search yielded direct links to 86% of program Web sites. The quality of presented information varied greatly among the 72 accessible Web sites. Program description (100%), fellowship application requirements (97%), program contact email address (85%), and research requirements (75%) were the most commonly presented components of fellowship information. Hand fellowship program Web sites can be accessed from the ASSH directory and, to a lesser extent, the NRMP directory. However, a Google search is the most reliable method to access online fellowship information. Of assessable programs, all featured a program description though the quality of the remaining information was variable. Hand surgery fellowship applicants may face some difficulties when attempting to gather program information online. Future efforts should focus on improving the accessibility and content quality on hand surgery fellowship program Web sites.

Perceptions of Emergency Medicine Residency and Hand Surgery Fellowship Program Directors in the Appropriate Disposition of Upper Extremity Emergencies

To survey emergency medicine (EM) residency and hand surgery fellowship program directors (PDs) to identify consensus in their perceptions of appropriate emergency care of upper extremity emergencies. We created a framework to group common upper extremity emergency diagnoses and surveyed PDs to evaluate the training background--EM, general orthopedic or plastic surgery, or hand fellowship--most appropriate to provide acute, point-of-care management for each of these diagnostic groupings. Responses were pooled and consensus was established with greater than 75% agreement between groups. We received 79 responses from hand fellowship PDs (90% response rate) and 151 responses from EM PDs (49% response rate). We identified consensus for the training background that PDs in both specialties felt was appropriate to care for 17 of 21 diagnostic groupings in the framework. There was a high level of consensus between EM and hand surgery PDs regarding diagnoses that acutely require training in hand surgery versus those that can be managed by an EM physician. Our diagnostic framework may help reduce unnecessary hand surgery consultation and may help to identify patients who do not require more specialized acute care and thus decrease unnecessary transfers. Economic and Decision Analyses IV.

The Association of the H-Index and Academic Rank Among Full-Time Academic Hand Surgeons Affiliated With Fellowship Programs

To evaluate the association between the Hirsch index (a measure of publications and citations) and academic rank among hand surgeons. This was a cross-sectional study of full-time academic hand surgeons within Accreditation Council for Graduate Medical Education-approved hand surgery fellowship programs in the United States and Canada. The study variables were classified as bibliometric (h-index, I-10 index, total number of publications, total number of citations, maximum number of citations for a single work) and demographics (gender, training factors). The outcome was academic rank (instructor, assistant professor, associate professor, professor, endowed professor). Descriptive, bivariate, and multiple regression statistics were computed. The sample was composed of 366 full-time academic hand surgeons; 86% were male and 98% had formal hand surgery fellowship training. The mean time since completion of surgical training was 17 ± 11 years. The distribution of primary faculty appointments was orthopedic surgery (70%) and plastic surgery (30%). Two hundred fifty surgeons (68%) were members of the American Society for Surgery of the Hand. The mean h-index was 10.2 ± 9.9 and was strongly correlated with academic rank. Gender was not associated with academic rank. Distribution of academic ranks was as follows: instructor (4%), assistant professor (28%), associate professor (40%), professor (22%), and endowed professor (5%). The h-index, years since completion of training, and American Society for Surgery of the Hand membership were associated with academic rank. The h-index had a high sensitivity and specificity for predicting academic rank. The h-index is a reliable tool for quantitatively assessing research productivity and should be considered for use in academic hand surgery. When evaluating candidates for academic promotion in hand surgery, the h-index is a potentially valuable tool for assessing research productivity and impact.

Accredited Hand Surgery Fellowship Web Sites: Analysis of Content and Accessibility

To assess the accessibility and content of accredited hand surgery fellowship Web sites. A list of all accredited hand surgery fellowships was obtained from the online database of the American Society for Surgery of the Hand (ASSH). Fellowship program information on the ASSH Web site was recorded. All fellowship program Web sites were located via Google search. Fellowship program Web sites were analyzed for accessibility and content in 3 domains: program overview, application information/recruitment, and education. At the time of this study, there were 81 accredited hand surgery fellowships with 169 available positions. Thirty of 81 programs (37%) had a functional link on the ASSH online hand surgery fellowship directory; however, Google search identified 78 Web sites. Three programs did not have a Web site. Analysis of content revealed that most Web sites contained contact information, whereas information regarding the anticipated clinical, research, and educational experiences during fellowship was less often present. Furthermore, information regarding past and present fellows, salary, application process/requirements, call responsibilities, and case volume was frequently lacking. Overall, 52 of 81 programs (64%) had the minimal online information required for residents to independently complete the fellowship application process. Hand fellowship program Web sites could be accessed either via the ASSH online directory or Google search, except for 3 programs that did not have Web sites. Although most fellowship program Web sites contained contact information, other content such as application information/recruitment and education, was less frequently present. This study provides comparative data regarding the clinical and educational experiences outlined on hand fellowship program Web sites that are of relevance to residents, fellows, and academic hand surgeons. This study also draws attention to various ways in which the hand surgery fellowship application process can be made more user-friendly and efficient.