Published 4/1/2016
Gerald R. Williams Jr, MD

Fellowship Accreditation: Finding the Way Forward

When I gave my incoming presidential address at the AAOS Annual Meeting in Orlando, I touched on the topic of fellowship accreditation—specifically, the unaccredited programs that provide orthopaedic fellowship training across the country. 

Just how prevalent are these programs? According to 2015 match statistics, there are currently 480 fellowship programs and 943 fellowship positions nationwide. When osteopathic programs are included, the numbers are even larger. While some of these programs are affiliated with an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency, many are stand-alone programs associated with individual surgeons or surgeon groups. Excluding hand surgery and sports medicine programs, approximately 70 percent of fellowships are not ACGME-accredited. Although the quality of fellowship education in orthopaedic surgery may be excellent, even in those fellowships that are not accredited by any organization, an accreditation pathway(s) for all fellowships might be a reasonable consideration to make the fellowship educational process more standardized and effective.

If we believe that specialization is a good thing for patients and our profession—as I, for one, do—there are some obvious questions to answer. First, is it acceptable that such a large proportion of our fellowships go unaccredited? If so, how do we confirm that all of our fellows are graduating with adequate training? If not, how do we increase the number of ACGME-accredited programs? If alternate fellowship accreditation pathways are to be established, which groups might be best suited to accomplish this?

ACGME accreditation
The ACGME offers accreditation in adult reconstruction, foot and ankle surgery, hand surgery, musculoskeletal oncology, orthopaedic sports medicine, orthopaedic surgery, orthopaedic surgery of the spine, orthopaedic trauma, and pediatric orthopaedics. In orthopaedic trauma, nine of the 50 programs that participate in the trauma fellowship match are ACGME-accredited. To earn this accreditation, fellowship programs must apply to the ACGME, and if accredited, they must maintain their accreditation by complying with various rules and regulations, which can be challenging. Moreover, recently adopted rules exclude any new stand-alone programs from ACGME accreditation and require all existing stand-alone programs to affiliate with an ACGME-accredited program.

While the American Board of Orthopaedic Surgery (ABOS) certifies orthopaedic surgeons in the United States who have completed an ACGME-accredited residency program and passed parts 1 and 2 of the ABOS examination, there is no general mandate that fellowship programs be ACGME-accredited. And yet, one cannot sit for the ABOS examination for subspecialty certification in surgery of the hand or sports medicine without first completing an ACGME-accredited fellowship in those areas of specialization.

The OTA pathway
The Orthopaedic Trauma Association (OTA) instituted its own fellowship accreditation pathway in 2013, in response to the rapid expansion of fellowships, variability in the fellowship experience, ACGME accreditation process duty hour requirements, and billing requirements that couple with ACGME-accredited programs. The short-term goal was to establish criteria defining high-quality educational standards and practices for orthopaedic trauma fellowship programs, while the long-term goal was to increase the future quality of orthopaedic trauma health care.

For the OTA to accredit a fellowship program, the program must be offered at a Level I or Level II trauma center, and must have greater than 400 surgical cases per fellow as well as an adequate faculty-to-fellow ratio. In addition, a director and at least one other faculty member must be active OTA members. Finally, the program must have an OTA-created and maintained core educational curriculum and a fellow case log.

The number of programs that have moved from ACGME accreditation to OTA accreditation in the past 3 years has grown steadily. This increase is expected to continue. Currently, 41 of the programs that participate in the trauma fellowship match are OTA-accredited. No other orthopaedic fellowship accreditation pathways exist, although specialty societies such as the Pediatric Orthopaedic Society of North America are actively exploring alternate accreditation pathways.

Academy efforts
So, what is the AAOS response to the current state of fellowship accreditation? After the 2015 AAOS Annual Meeting, then-AAOS President David D. Teuscher, MD, created a project team to explore this issue, charging its members with the following tasks:

  • Querying the OTA as to the principles, policies, and practices of its accreditation of orthopaedic trauma fellowships
  • Exploring the desire of other specialty societies to adopt similar options for accreditation
  • Identifying the advantages and disadvantages of AAOS sole or dual accreditation of fellowships
  • Providing a final report and recommendation to the AAOS Board of Directors

The project team, which included representatives from virtually every orthopaedic specialty society, held four conference calls over 5 months and exchanged many emails. The discussions were extensive—and, at times—spirited. A few common themes materialized. First, there was universal agreement that the ACGME process was difficult to comply with and must be improved if greater adoption is to be realized. Second, there was widespread (but not unanimous) support for pursuing an alternate accreditation pathway. Third, participants agreed there is a potential role for the Academy to play in supporting the specialty societies as they develop and administer fellowship accreditation pathways.

The project team's recommendations, delivered in February 2016, were approved by the AAOS Board of Directors and shared with the leadership of the specialty societies. These recommendations reflect the belief that improvement in the ACGME process may be possible and could lead to greater adoption of ACGME accreditation by orthopaedic fellowships. In addition, they acknowledge that further exploration of an alternative pathway or pathways for fellowship accreditation is also prudent. Three possible ways forward exist, as follows:

  1. Do not make any changes, resulting in a relatively large percentage of orthopaedic fellowships remaining unaccredited.
  2. Create an alternate accreditation pathway or pathways in collaboration with orthopaedic specialty societies.
  3. Work with the ACGME to modify the accreditation process so that more fellowships seek and obtain ACGME accreditation.

A Fellowship Accreditation Task Force has been created that will include representatives from every orthopaedic specialty that wishes to be involved. This task force has been charged with the following goals:

  1. Creating specialty-specific alternate fellowship accreditation pathways
  2. Identifying a specific role for AAOS (eg, creating and maintaining a fellow case log as well as faculty and/or program evaluations, infrastructure for keeping demographic information on fellowships, and anything else the committee suggests)
  3. Designing a business plan for creating and maintaining alternate pathways
  4. Initiating conversations with the ABOS about the possibility of recognizing an AAOS/specialty society endorsed-accreditation pathway as an alternative to ACGME accreditation for subspecialty certification in sports medicine or surgery of the hand
  5. Initiating conversations with the ACGME regarding possible ways of enhancing current accreditation pathways
  6. Providing the AAOS Board of Directors with a recommendation regarding whether to pursue implementation of an alternate accreditation pathway

The road ahead
Clearly, pursuing alternate fellowship pathways will present some significant challenges, the most obvious of which is the current requirement for sports medicine and hand fellows to complete an ACGME-accredited fellowship to sit for the ABOS subspecialty certificate examination. The American Orthopaedic Society for Sports Medicine, for example, has invested substantially in creating and developing the ACGME pathway and would like to see it improved and maintained.

Other potential issues could involve creating new pathways for surgical specialties that include nonorthopaedic physicians, such as hand surgery (plastic surgeons and general surgeons) and spine surgery (neurosurgeons). In addition, costs associated with initiating and administering new pathways are unknown.

In my estimation, continuing to explore the present and future of orthopaedic fellowship accreditation is an important activity for the Academy and all specialty societies. I look forward to the task force report.