Practice Patterns Among Hand Surgeons According to Primary Residency Training

Abstract

Introduction Hand surgery fellowships accept applicants from 3 different residencies: general surgery, orthopedic surgery, and plastic surgery. Although all of these specialties culminate into a board-certified hand surgeon, each specialty receives drastically different training in residency, which can have effects on which procedures these surgeons feel comfortable performing in their own practices. This study aims to compare practice patterns and complication rates among hand surgeons by residency training. Methods The National Surgical Quality Improvement Program database was queried between the years of 2014 and 2018 for all Current Procedural Terminology codes pertaining to upper-extremity surgical procedures performed below the elbow. Procedures not performed by a general, orthopedic, or plastic surgeon were excluded, as well as polytraumas. Procedures were then stratified by anatomic region, tissue type, and primary specialty of the attending surgeon. Data collected included the number of each procedure, patient complexity, and complications. Statistical analysis consisted of a t test for continuous variables, χ 2 analysis for categorical variables, and linear regression analysis to compare complications rates between specialties. Results A total of 76,980 unique cases were included in our analysis: 4979 (6.4%) at the elbow, 43,680 (56.7%) at the forearm/wrist, 23,284 (30.2%) at the hand, 1421 (1.8%) flaps/grafts, 285 (0.4%) vascular, and 3331 (4.3%) neurological. Orthopedics performed most (79.5%) of the procedures, whereas plastic surgeons and general surgeons performed 17.3% and 3.1%, respectively. There were also significant differences by anatomic location/type of procedure, with orthopedic surgeons performing 99.2% of procedures at the elbow but only 67.7% of procedures at the hand. Linear regression analysis showed general surgeons had the lowest complication rates. Conclusions Our data show significant differences in the number of upper-extremity surgeries performed by surgeons from each specialty at different anatomic locations. This could be due to differences in training during residency or proportionately more orthopedic surgeons being “full-time” hand surgeons. These data could affect hiring patterns in hospitals seeking hand surgeons depending on the variety of pathology encountered at that particular institution.

Impact of Orthopedic Hand Surgery Fellowship Training on Hand Surgery Cases Performed by Plastic Surgeons in the United States

“…13 Studies using the National Surgical Quality Improvement Program also demonstrate that orthopedic surgery trained hand surgeons perform more bone, fracture, joint, and tendon cases. 14,15 Conversely, plastic surgery-trained hand surgeons perform more soft-tissue reconstruction cases. Reasons for these disparities are likely multifactorial and include the perception of referring physicians, clinical care protocols at local hospitals, and hand surgeon comfort.…”

Analysis of Strengths in Exposure to Cases During Plastic and Orthopaedic Hand Surgery Fellowships

“…Ultimately, hand surgery training discipline affects future practice patterns, which likely reflects the perception of referring providers and intrinsic motivation. [10][11][12][13] The importance of training well-rounded hand surgeons will increase as the burden of musculoskeletal disease increases among older populations and rural areas. 20 In summary, the specialty of hand surgery fellowship programs affects the volume of patients reported during hand surgery fellowship.…”

“…Previous studies have described disparities in hand surgery training by specialty with real-world implications on future practice patterns. [5][6][7][8][9][10][11][12] Notable differences exist by specialty regarding tested topics on in-service training examinations and reported resident case volumes. During residency, plastic surgeons often report more soft-tissue reconstruction cases, while orthopaedic surgeons report more bone and joint cases.…”

“…These differences manifest into future practice patterns of hand surgery attendings, with hand surgeons performing more cases in the areas they feel more comfortable. [10][11][12] Objective data on the surgical training experiences of hand surgery fellows can help inform prospective applicants during orthopaedic and plastic surgery residency. Furthermore, the potential "cross-pollination" of surgical training by discipline may help round out surgical experiences during fellowship training.…”

“…These differences manifest into future practice patterns of hand surgery attendings, with hand surgeons performing more cases in the areas they feel more comfortable. 10-12…”