Pass/Fail: Fellowships and Patient Safety, An Interview with Dr. Robert S. Bray, Jr. - Orthopedics This Week

Dr. Robert Bray, Founding Director and CEO of D.I.S.C. has had Fellows of all talents and characteristics pass through his doors. He says, “Fellows, like fellowships, differ widely. Most of the fellows I work with start out by thinking that they’re ready to do the procedure themselves. They are often frustrated, however, because I start them out very slowly and at first let them do almost nothing. They observe me first, and then I gradually allow them to do pieces of the surgery—first exposure, then drilling, etc.—all based on their competency levels. In general, Fellowship mentors differ in how quickly they bring Fellows along in the OR.” 

 

Is he ready? Are her hands sufficiently dexterous? Is he fluent in the details of this procedure? Such are the questions that veteran surgeons must address when handing responsibility—and surgical drills—to fellows.

 

Is he ready? Are her hands sufficiently dexterous? Is he fluent in the details of this procedure? Such are the questions that veteran surgeons must address when handing responsibility—and surgical drills—to fellows.

 

Dr. Robert Bray, Founding Director and CEO of Diagnostic and Interventional Spinal Care (D.I.S.C.) in Marina del Rey, California, has had fellows of all talents and characteristics pass through his doors. He says, “Fellows, like fellowships, differ widely. Most of the fellows I work with start out by thinking that they’re ready to do the procedure themselves. They are often frustrated, however, because I start them out very slowly and at first let them do almost nothing. They observe me first, and then I gradually allow them to do pieces of the surgery—first exposure, then drilling, etc.—all based on their competency levels. In general, fellowship mentors differ in how quickly they bring fellows along in the OR.”

 

So you can’t just hand things off to a fellow, thinking, “Great. That’s one less thing I have to do.” Dr. Bray explains, “What a lot of people don’t know is that it’s actually a lot of work to have a fellow. There are many surgeons who view having fellows as a chance to withdraw themselves from the ‘grunt work’ of things such as labs, putting a chart together, doing a history and physical, surgery prep, and weekend rounds. The problem with this is that many of those things are integral to patient care. I have to know my patient…and the only way I’m going to do that is to have ‘face time’ with them.”

 

“I am involved in labs, do rounds with the patients, etc. Fellows really need to be observed by a mentor every step of the way. I have seen cases where fellows have been allowed to operate without much supervision—or no supervision—and got into trouble with the nerve linings and screw placement.”

 

Advocating for staying involved, Dr. Bray says, “Take the old adage that to get a good outcome you need to have the right patient, the right surgery, done right. If you offload a number of responsibilities then how will you know you are hitting these marks? There is a careful decision making process involving patient evaluation and the selection of the appropriate procedure. When the wrong procedure is done it is sometimes because the mentor didn’t put enough time into choosing the right procedure.”

 

One thing is for sure. Surgeons didn’t become surgeons to have their hands tied behind their backs. Dr. Bray: “There are two types of fellowships, one in which trainees are active and one in which they just observe. You can’t ever completely learn just by observing. At some point before you are ‘let loose’ on the public you should have hands-on experience that is properly supervised. Actually, I am of the opinion that there should be a totally different certificate for those individuals who have done an observational only fellowship.”

 

A patient may think that because Dr. X has completed a fellowship, he or she is fully trained and competent. Speaking to this issue of quality, Dr. Bray states, “The fact that there is no rating system for fellows is controversial and is something that needs to be worked out. It’s usually a pass/fail designation…and hardly anyone is designated as failing. When someone gets a certificate at the end of the year it doesn’t say that the person is competent or got a high score. I have had frank discussions with some fellows who have completed the fellowship year, but needed more time to master different concepts/procedures. I’ve advised them to do more time somewhere else. Fortunately, they have taken this advice.”

 

“Where is the umbrella and the measuring stick?” asks Dr. Bray. “At present we have no superstructure that regulates fellowships. Nor do we have any type of ranking of the programs for spine. It seems to go by subspecialty, i.e., for spine surgery there is no approving structure, whereas for sports medicine there is an AAOS approved fellowship. Having oversight and solid guidelines would help ensure high quality training. For example, we need a guideline saying that you must be present at every case your fellow does. And, as the situation is now, any orthopedist or neurosurgeon in private practice can take out an ad saying, ‘I do spine surgery and am accepting fellows.’ Then at the end of the year he or she just prints a certificate off the computer. That is just too random.”

 

And now to the less tangible, but important topic of vainglory. Even if the fellow who casts his shadow upon your doorstep is short of stature, his ego may be large. “While fellows can and should have a healthy ego, they have to be open to learning new things,” says Dr. Bray. “On occasion I have a new fellow who wants to show everyone ‘how it’s done,’ at which point I make it clear that this is not the reason they’re here. Fortunately, with years of experience behind me, I can demonstrate to them there is still a lot to learn. Once the fellow realizes this they usually move forward quickly. It really depends on the individual. I have some people doing a lot by the three month mark, but with others I have to take things more slowly. And yes, for those who have to wait longer, it’s tough on their egos. But they do catch up at some point.”

 

Dr. Robert S. Bray, Jr. is widely recognized as one of the world’s most experienced and qualified neurological spinal surgeons. Specializing in minimally invasive techniques, he has performed over 9,500 microsurgical procedures and is at the forefront of the revolutionary innovations taking place in his field. He serves as the Founding Director & CEO at the D.I.S.C.

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