Dr. Richard Guyer: Today's spine fellowship

Richard Guyer, MD, Orthopedic Spine Surgeon, Texas Back Institute -   Print  |

This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World " edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.

When spine fellowships were first started in the 1960s and 1970s spine surgery sub-specialization was limited. The first fellowships were in spinal deformity, trauma or spinal cord injury, degenerative lumbar and cervical fellowships. Originally spine fellowships were more of a preceptorship concentrating on a particular surgeon’s expertise.

With the formation of spinal implant companies and advent of modern internal fixation the options for treating complex spinal disorders have multiplied many fold. Scoliosis fusions are now being carried out not just on children but also on adults well into the seventh and eighth decades. Cervical spine fixation has progressed from simple wiring techniques and some early screw fixation and to the common use of lateral mass screws and pedicle screws. With the current fixation that is now available, the spine can be fixed from the occiput down to the sacrum with the high reliability of a solid fusion.

With this is a background, the early spine fellowships were designed to give the fellow experience in a single area of spine. There were deformity surgeons, there were degenerative surgeons who operated primarily on the lumbar spine, and there were surgeons who specialize in spinal cord injury. However, over the last 50-60 years, spine has become so complex that a surgeon may specialize in pediatric or adult deformity, cervical disease, lumbar degenerative disease, minimally invasive surgery, arthroplasty, trauma and tumor. The spine literature in the beginning started with the formation of a single spine journal. Now, literally, there are dozens of printed journals and on-line journals. The number of spine societies has also multiplied. The amount of information available to the current fellows is staggering. There are also so many spine meetings one could attend a different meeting every week. We are constantly being bombarded with information and fortunately the quality of studies has also been improving.

In 1986, we started the Texas Back Institute Spine Fellowship with one fellow and with me as Director. At that time, it was strictly a preceptorship much like my partners Ralph Rashbaum and Stephen Hochschuler and I had trained in spine surgery. As Texas Back Institute grew from 3 surgeons to 18 surgeons, so did our fellowship. We soon were taking 5 fellows per year. Jack Zigler joined Texas Back in 1996 and became Co-Director of our program following his Directorship of the Rancho Los Amigos Fellowship program from 1982 to 1995. Since the inception of our program we have trained 129 national and international fellows from 33 states and 11 nations. We have over 120 visiting fellows from around the world.

We have continually improved our fellowship morphing into a formal well-rounded comprehensive program. Partly this was achieved through undergoing ACGME accreditation which gave us a framework to identify our weaknesses as well as our strengths. Although ACGME accreditation is not widespread across the nation, in fact, only 16 programs are ACGME approved out of the more than 80 programs. Accreditation has given us the discipline to grow our fellowship into one of the best well-rounded programs in the US. We filled in the gaps in our program to give the fellows the best possible experience.

There are good reasons that many academic programs are not accredited, which has more to do with funding issues not quality. On the other hand, within the last couple of years there has been a move to form a new accrediting body that has multiple orthopedic spine society support. This will allow all spine fellowship programs who meet the basic requirements to be accredited by a single uniform body. There still is no uniform agreement regarding accreditation between the orthopedic and neurosurgery disciplines however.

Academics has been extremely important to the founders of TBI (Hochschuler, Rashbaum, and Guyer) and our fellowship program. The Texas Back Institute Research Foundation, a 501 3c nonprofit foundation, was formed in 1985 and was privately funded with $200,000 per year for ten years coming directly from the practice. Through this mechanism we funded all our early research ourselves. We published the earliest studies in discography which lead to the Dallas Discogram Description which is still utilized today. We also published on technology such CT, MRI, and chymopapain. Under John Regan thorascopic surgery was developed.

We have also participated in dozens of FDA IDE trials starting with electrical bone stimulation, disc replacement studies and stem cell studies. We have been leaders in total disc replacement and have participated in over 12 FDE IDE trials for cervical and lumbar disc replacement and our surgeons in many instances were the lead principal investigators and have published the seminal papers in this area.

While the fellows themselves are engaged in ongoing projects, we have not rested on our laurels but continue to push the envelope of technology with robotic surgery with Izzy Lieberman taking the lead and navigation with Raj Arakal. We are the first privademic practice to develop a human gait lab 5 years ago. Under the direction of our surgeons and Ram Haddas, we have published over 25 articles and are pioneering new ways of determining objective patient evaluations after surgery. We have also developed a Total Disc Replacement registry that goes back to 2000 and includes over 300 patients and will be publishing landmark papers.

In order to teach fellows and give them appreciation of academics they also must have good role models. We have had Presidents of all the major spine societies: Richard Guyer, President of NASS, Stephen Hochschuler, ISASS, Jack Zigler, ISSAS and ASIA, and Scot Blumenthal, future President of ISSLS. Our other surgeons are involved in all the major spine societies including the CSRS, Scoliosis Research Society, ISMISS in addition to the ones above.

To date, we have published over 250 peer reviewed articles, authored or edited 23 books, had nearly 800 presentations, over 500 poster presentations, and participated in over 500 symposia at major national and international conferences.

With 17 surgeons, we have organized our practice into various tracks or silos. In Spine Deformity, Izzy Lieberman, Marc Kyanja, Blake Staub, Raj Arakal and Ted Belanger lead this charge. We have a level 1 trauma hospital so that this Trauma silo is led by Raj Arakal, Ted Belanger, Akwasi Boah, Tom Kosztowski, and Kevin Ju. The Tumor silo is headed up by Izzy Lieberman. The Degenerative silo includes Mike Hisey, Rey Bosita, Michael Duffy, Jessica Shellock, and Stephen Tolhurst. Complex cervical silo includes Kevin Ju, Ted Belanger, and Raj Arakal. The Disc Replacement silo includes Richard Guyer, Jack Zigler, Scott Blumenthal, and Jessica Shellock. MIS includes Peter Derman, Steve Tolhurst, Mike Hisey, Blake Staub, and Kevin Ju. With these divisions we can expose our 5 fellows to a comprehensive and broad range of spine pathology.

In addition to our in-house activities, our surgeons are involved in missions to Ethiopia (Ted Belanger) and Uganda (Izzy Lieberman, Mark Kyanja and Michael Hisey). These are life changing experiences for the fellows who go on these missions. The pathology is endless and far beyond anything they could be exposed to in the US. We have also been selected to be spine center of excellence through the PreferUS organization that trains Chinese spine surgeons. Our surgeons go to China to work with Chinese surgeons and the Chinese surgeons also come to TBI for several months at a time for advance spine training.

As a result of the breadth and width of our program, TBI has one of most sought-after fellowship programs in the country and compete with the best academic programs. Since the universal participation of the San Francisco match program, TBI interviews 40 applicants per year of the approximately 80 that apply and routinely matches with 5 outstanding fellows.

Currently today’s well-rounded spine fellowship should include faculty that have experience in trauma, tumor, pediatric and adult deformity, adult degenerative lumbar disease, cervical disc disease, minimally invasive surgery, disc replacement and exposure to navigation and robotic surgery. Academically, the fellow should be exposed to a core curriculum that is given to them by all the participating faculty members. A monthly journal club is mandatory. There should also be regularly scheduled if not weekly conferences including an indications and interesting cases conference and M&M conferences. Grand round lectures by visiting professors, local faculty and fellows should occur on a weekly basis.

After each rotation the fellow should undergo evaluation by the faculty members with whom they worked. They would then meet with the director(s) to review their evaluations so that they can recognize their strengths and weaknesses and continue to improve their knowledge base and skills.

Years ago, Dr. Vert Mooney, who was the Chairman of the Department of Orthopedics at University of Texas Southwestern Medical School, suggested that orthopedic residency should be shortened by a year or 2, allowing the resident to engage in a 2 fellowship programs. It has also been discussed that perhaps there should be a spine residency. Although these ideas may seem radical, the complexity of spine continues to increase so that these ideas in the future may come to fruition.

Previous chapters:

Challenges, risks and opportunities in today's spine world

Spine care - Balancing cost with innovation

What are big data and predictive analytics

Predictive Analytics and Machine Learning

The HSS Spine Care Model, Part 1

The HSS Spine Care Model, Part 2

The Rothman Model, Part 1

The Rothman Model, Part 2

The History of Texas Back Institute

Texas Back Institute, Part 2

Private practice vs. hospital employee: Where we are today and why

ASCs: The economics of ASCs

Episodes of care and bundled payments

Episodes of care and bundled payments, a sustainable approach

Dr. Scott Blumenthal on specialty hospitals

The uncertainty of pain

Spine industry trends in new technologies and market challenges

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