Special Topic The Effect of Residency and Fellowship Type on Hand Surgery Clinical Practice Patterns Karan Mehta, B.S. Paul Pierce, M.D. David T. W. Chiu, M.D. Vishal Thanik, M.D. New York, N.Y.
Background: The Accreditation Council for Graduate Medical Education requires accredited fellowship programs to exhibit proficiency in six broadly defined domains; however, core competencies specifically mandated for hand surgery training have yet to be established. Several studies have demonstrated significant disparities in exposure to essential skills and knowledge between orthopedic surgery– and plastic surgery–based hand surgery fellowship programs. To determine whether significant discrepancies also exist after fellowship between hand surgeons trained in orthopedic surgery and those trained in plastic surgery, clinical practice patterns were evaluated. Methods: A 20-question survey was created and distributed electronically to American Society for Surgery of the Hand and American Association for Hand Surgery members. Responses were compared using descriptive statistics. Results: Nine hundred eighty-two hand surgeons (76 percent orthopedic and 24 percent plastic) responded, representing a 39 percent response rate. Most plastic surgery hand practices were academic-based (41 percent), whereas orthopedic practices were private (67 percent). More orthopedic hand surgeons worked in multipractitioner practices than plastic surgeons (54 percent versus 30 percent; p < 0.0001). Orthopedic hand surgeons performed a higher percentage of hand cases in their practice facilities (86 percent versus 71 percent; p < 0.0001). Plastic surgeons performed more congenital hand (56 percent versus 35 percent; p < 0.05) and digital replantation cases (53 percent versus 22 percent; p < 0.05) but treated significantly fewer open reduction and internal fixation distal radius fractures. Conclusions: Orthopedic and plastic surgery hand surgeons differ significantly in their clinical practice patterns. Differences in clinical exposure during training are reflected in practice and persist over time. Referral patterns and practice situations are also contributors to ultimate practice patterns. (Plast. Reconstr. Surg. 135: 179, 2015.)
A
ccording to the National Resident Matching Program, hand surgery has demonstrated continued growth and popularity as a surgical subspecialty.1 Each successive year from 2009 to 2014 has produced increasing numbers of applicants, with an increase from 127 to 205 candidates yearly during this period. The growth of professional organizations such as the American Society for Surgery of the Hand and the American Association for Hand Surgery also supports this trend.2 Currently, applicants with backgrounds in orthopedic, plastic, or general surgery are eligible From the Institute of Reconstructive Plastic Surgery, New York University. Received for publication May 27, 2014; accepted July 21, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000786
to apply to the 77 hand surgery fellowship programs approved by the Accreditation Council for Graduate Medical Education. These consist of 60 orthopedic surgery–based programs, 16 plastic surgery–based programs, and one general surgery–based program.1,2 The Accreditation Council for Graduate Medical Education requires fellowship programs to exhibit proficiency in six broadly defined domains; however, there is no Disclosure: The authors have no financial interests to declare in relation to the content of this article. A Video Discussion by residents Yash Avashia, Laura Tom, and John Fischer accompanies this article. Go to PRSJournal.com and click on “Video Discussions” in the “Videos” tab to watch.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • January 2015 standardized set of core competencies specified for hand surgery fellowship programs.3–5 This lack of a uniform curriculum allows for variable training experiences between the three types of hand surgery fellowships. Indeed, Sears et al. recently found that plastic and orthopedic hand fellowship program directors emphasized the importance of clinical practices and procedures that were more in line with their respective primary disciplines.6 A study conducted by Aliu and Chung discovered significant variations in exposure to essential skills and knowledge topics between plastic and orthopedic fellowship graduates.7 Another widening discrepancy between plastic surgery– and orthopedic surgery–trained hand surgeons is the changing representation in the field of hand surgery. In particular, plastic surgeons have been noted to have a diminished presence in hand surgery as evidenced by decreasing fellowship and Certificate of Added Qualifications (now known as Certification in the Subspecialty of Surgery of the Hand) applications and American Society for Surgery of the Hand memberships.2,8,9 This is seen despite an increasing number of plastic surgery residency programs and positions. Although differences in fellowship training and representation in the field of hand surgery between hand surgeons trained in orthopedic surgery and those trained in plastic surgery have been studied, no studies currently examine whether persistent differences exist in clinical practice. It is also unclear whether respective differences in training exposures during fellowship could explain differences in clinical practice. Therefore, to identify whether discrepancies exist between plastic surgery and orthopedic surgery hand surgeons following fellowship, clinical practice patterns were studied.
PATIENTS AND METHODS This study was performed in accordance with the Declaration of Helsinki. The American Society for Surgery of the Hand and the American Association for Hand Surgery were contacted for participation in this study. Following approval from both organizations, a list of members’ e-mail addresses was obtained. A total of 2522 U.S. members of both organizations were invited to partake in the study. A 20-question survey was designed to assess the clinical practice patterns of orthopedic surgery and plastic surgery hand surgeons (Appendix). The survey consisted of three essential components: training background/experience, practice model/structure, and hand case type/volume. An
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initial 25-item survey was created using questions and core competencies identified in previous studies.10–12 This was then sent to the chief and senior faculty of hand surgery in the Department of Plastic Surgery at this institution. After feedback and revision, the survey was pilot tested in a cohort of both orthopedic surgery– and plastic surgery– trained hand surgeons to identify omitted and redundant items. Five items were then removed and the survey was finalized and uploaded using an online survey tool provided by Qualtrics, LLC (Provo, Utah). A cover letter with a link to the survey was then sent electronically to the 2522 members of the American Society for Surgery of the Hand and the American Association for Hand Surgery. Two reminder e-mails were sent 2 weeks apart, and participants had 8 weeks to respond to the survey. All responses were collected in an anonymous manner. For outcomes analysis, responders were divided into two cohorts: hand surgeons who completed a plastic surgery residency and hand surgeons who completed an orthopedic surgery residency. This allowed for a direct comparison of responses between hand surgeons trained in orthopedic surgery and those trained in plastic surgery residency. Hand surgeons trained in general surgery residency were not evaluated in this study because of their limited representation in hand surgery. For multiple-choice questions, the percentage of individuals who selected each option was tabulated. For question 13, only the most common form of reimbursement indicated by a rating of 1 of 4 was analyzed. For questions 14 and 15, the mean percentage of a practice consisting solely of hand cases and the mean number of hand cases was calculated, respectively. For question 20, the mode or most commonly indicated procedure that surgeons felt poorly prepared for by their hand fellowship was determined. Responses were also stratified based on both primary residency and fellowship type. Data were then analyzed using a t test or chi-square test where appropriate, with a value of p < 0.05 used to determine whether a statistically significant difference existed between the responses of hand surgeons trained by means of orthopedic and plastic surgery residency.
RESULTS Demographics and Training Background A total of 982 responses were received, representing a 39 percent response rate (Table 1). Seventy-six percent (n = 746) of the respondents were
Volume 135, Number 1 • Hand Surgery Clinical Practice Patterns Table 1. Demographic Characteristics of Survey Respondents and Training Background/Experience Characteristic Primary board certification Orthopedic surgery Plastic surgery Completion of hand fellowship Orthopedic hand surgeons Plastic hand surgeons Type of hand fellowship completed Orthopedic hand surgeons Orthopedic based Plastic surgery based Combined Plastic hand surgeons Orthopedic based Plastic surgery based Combined Years in practice Orthopedic hand surgeons Plastic hand surgeons Region of the country Midatlantic (N.Y., Pa., N.J.) South Atlantic (Del., Md., D.C., Va., W.Va., N.C., S.C., Ga., Fla.) Midwest (Wis., Mich., Ill., Ind., Ohio, Mo., N.D., S.D., Neb., Kan., Minn., Iowa) South (Ky., Tenn., Miss., Alaska, Okla., Texas, Ark., La.) West (Idaho, Mont., Wyo., Nev., Utah, Colo., Ariz., N.M., Alaska, Wash., Ore., Calif., Hawaii)
Value 76% 24% 99% 91% 76% 1% 23% 41% 26% 33% 15.6 16.2 16% 19% 24% 11% 22%
orthopedic surgeons and 24 percent (n = 236) were plastic surgeons. The two groups showed a similar number of years in practice: 15.6 years for orthopedic surgery and 16.2 years for plastic surgery. Ninety-nine percent of orthopedic surgeons completed a hand fellowship compared with 91 percent of plastic hand surgeons. Practice Patterns Significantly more orthopedic surgery hand surgeons were found to be in private practice, compared with plastic surgery–trained hand surgeons (67 and 44 percent, respectively; p < 0.0001) (Table 2). Conversely, 41 percent of plastic surgery hand surgeons were involved in academia compared with only 25 percent of orthopedic surgery hand surgeons (p < 0.0001). The majority, 54 percent, of orthopedic surgery hand surgeons functioned in multipractitioner practices, which consist of many orthopedic specialists working together. Only 30 percent of plastic surgery hand surgeons worked in multipractitioner practices. A significantly greater proportion of plastic surgery hand surgeons practiced in urban areas compared with orthopedic surgery hand surgeons (60 and 44 percent, respectively; p = 0.0002). Orthopedic surgery hand surgery practices were located mostly in suburban settings.
Ambulatory surgical centers and practiceowned operating rooms were used to a greater extent by orthopedic surgery hand surgeons, whereas plastic surgery hand surgeons most often used hospital operating rooms. Both plastic surgery and orthopedic surgery hand surgeons received most of their referrals from primary care physicians, 41 percent and 49 percent, respectively. However, plastic surgery hand surgeons reported a greater proportion of referrals from the emergency department (plastic surgery, 30 percent; orthopedic surgery, 20 percent), whereas orthopedic hand surgeons reported relatively more referrals from colleagues (plastic surgery, 26 percent; orthopedic surgery, 19 percent). With regard to reimbursement, private insurance was the most commonly accepted form of payment among both specialties (orthopedic surgery, 85.6 percent; plastic surgery, 66.9 percent). Out-of-pocket payments were more often accepted by plastic surgery hand surgeons compared with their orthopedic surgery counterparts (p = 0.0003). Interestingly, Medicare and Medicaid were also more commonly accepted by plastic surgery hand surgeons. Analysis of Hand Case Volumes and Types Eighty-six percent of the total cases performed by orthopedic surgery hand surgeons consisted of hand cases, as opposed to 71 percent for plastic surgery hand surgeons (p < 0.0001). Furthermore, orthopedic surgery hand surgeons also performed more hand cases per year than plastic surgery hand surgeons (468.8 and 396.3 cases per year, respectively; p = 0.002) (Table 3). Although most hand surgeons from both specialties reported no change in hand caseload over the years, a greater number of plastic surgery hand surgeons indicated a substantial decrease in hand cases over the years compared with orthopedic surgery hand surgeons (11 and 4 percent, respectively; p < 0.0001). When analyzing cases over the past 12 months, orthopedic surgery hand surgeons performed significantly more open reduction and internal fixation of distal radius fracture repairs, operative repairs of carpal bone fracture/dislocation, cubital tunnel releases, operative treatments of basal joint arthritis, and palmar fasciectomies for Dupuytren contractures than did plastic surgery hand surgeons (Table 4). Plastic surgery hand surgeons performed more nail-bed injury repairs, digital replantations, and congenital hand procedures. Interestingly, orthopedic surgery hand surgeons indicated that they wished their fellowship better trained them for congenital hand and digital
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Plastic and Reconstructive Surgery • January 2015 Table 2. Practice Patterns Orthopedic Hand Surgeons (%) Practice type Academic Private Other Practice structure Single practitioner Multiple practitioners Multispecialty Faculty practice Other Practice setting Urban Rural Suburban Type of hospital affiliated with most Private Community Government Operate most frequently Hospital Ambulatory center Practice owned OR Source of most referrals ED Primary care physician Colleague No relationship Other Most accepted reimbursement Out-of-pocket Private insurance Medicare Medicaid
Plastic Hand Surgeons (%)
p*
25 67 8
41 44 15
0.05
32 56 12
60 35 5
0.05 >0.05 >0.05
1.88 85.6 9.93 2.6
6.3 66.9 16.9 9.86
0.0003 0.05 >0.05 0.05
15 11 26 30 18
20 8 28 26 18
>0.05 >0.05 >0.05 >0.05 >0.05
No. of hand cases per year Percentage of practice consisting of hand cases Trend of hand cases over the years Substantial increase Slight increase No change Slight decrease Substantial decrease Is the amount of hand cases less than you would like? Yes No If yes, why? Lack of referral Lack of demand Oversaturation Personal choice Other
Table 4. Most Commonly Performed Procedures in the Past 12 Months Procedure Carpal tunnel release Trigger finger release Operative treatment of hand infection Ganglion cyst excision CRPP/ORIF phalangeal fracture CRPP/ORIF metacarpal fracture ORIF distal radius fracture Operative repair of carpal bone fracture/dislocation Repair nail-bed injury Flexor tendon repair Extensor tendon repair Nerve repair Cubital tunnel release Operative treatment of basilar joint arthritis Palmar fasciectomy for Dupuytren contracture Xiaflex† injection for Dupuytren contracture Digital replantation Congenital hand Of the cases listed above, which do you wish your fellowship better trained you for?
Orthopedic Hand Surgeons (%)
Plastic Hand Surgeons (%)
99 99 92 98 97 96 95* 93* 88* 94 95 95 98* 94* 88 57 22* 35*
97 98 90 95 95 94 61* 80* 96* 97 95 97 87* 77* 80* 53 53* 56*
Congenital hand digital replantation
ORIF distal radius fracture
CRPP, closed reduction and percutaneous pinning; ORIF, open reduction and internal fixation. *Statistically significant difference (p < 0.05). †Auxilium Pharmaceuticals, Inc., Philadelphia, Pa.
In an article by Higgins examining the diminishing presence of plastic surgeons in hand surgery, the model of the “part-time hand surgeon” was examined.8 In that article, he postulated that part-time hand surgeons were “more widely encountered and accepted in plastic surgery than it is in orthopedic surgery.” It was suggested that a part-time hand surgeon would be defined as 50 percent or less hand surgery. In our data set, plastic surgery hand surgeons claimed 71 percent of volume of hand cases compared with 86 percent for orthopedic surgery hand surgeons. Although this is above the 50 percent cutoff asserted, it is clear that plastic surgery hand surgeons have a lower
percentage of hand cases of their total volume, and that they are more likely to want to increase their volume of hand cases. He also went on to note that in such a practice a higher percentage of cases were likely to come from trauma and the emergency room and were less likely to be a referral source for elective cases. Again, our data support this hypothesis, demonstrating higher rates of emergency room referrals and higher rates of hospital operating room use, combined with lower rates of referrals from colleagues. Plastic surgery hand surgeons were more likely to want to increase their volume of hand surgery, which suggests that the perception of a part-time hand
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Plastic and Reconstructive Surgery • January 2015 Table 5. Procedures Stratified by Fellowship Type
Procedure Carpal tunnel release Trigger finger release Operative treatment of hand infection Ganglion cyst excision CRPP/ORIF phalangeal fracture CRPP/ORIF metacarpal fracture ORIF distal radius fracture Operative repair of carpal bone fracture/dislocation Repair of nail-bed injury Flexor tendon repair Extensor tendon repair Nerve repair Cubital tunnel release Operative treatment of basilar joint arthritis Palmar fasciectomy for Dupuytren contracture Xiaflex injection for Dupuytren contracture Digital replantation Congenital hand
Plastic Surgeons with Orthopedic Hand Fellowship (%)
Plastic Surgeons with Plastic Hand Fellowship (%)
Orthopedic Surgeons with Orthopedic Hand Fellowship (%)
Orthopedic Surgeons with Plastic Hand Fellowship (%)
100* 100 95 98 98 96 74*
92* 95 85 92 92 90 49*
99† 100 94† 98† 97† 96 96
88† 100 50† 75† 75† 88 88
91* 96 98 96 98 96* 86* 79* 67* 53 61
69* 90 92 92 92 67* 62* 56* 31* 54 41
93 89† 95 95† 95 98 95† 89 57 21 34
100 63† 88 75† 88 100 75† 88 50 13 50
CRPP, closed reduction and percutaneous pin fixation; ORIF, open reduction and internal fixation. *Pairs of asterisks indicate a statistically significant difference (p < 0.05). †Pairs of daggers indicate a statistically significant difference (p < 0.05).
surgeon may be attributable more to circumstance than to physician preference. In a series of recent studies by Aliu and Chung, it was demonstrated that significant variations exist in training between plastic surgery and orthopedic surgery hand surgeons.7 In areas such as distal radius nonunion, distal radius/ulna open reduction and internal fixation, and intracarpal fusion, plastic surgery hand surgeons reported inadequate training. These deficiencies may influence further practice patterns as evidenced in our data set where plastic surgery hand surgeons were much less likely to perform these cases in the past 12 months. The certainty of this relationship is not definitive, however. In that same series by Aliu and Chung, orthopedic surgery hand surgeons did not claim inadequacy in replantation or congenital hand, yet in our survey, they performed significantly fewer of these procedures than their plastic surgery colleagues. A study conducted by Elliot et al. supported this finding by demonstrating that hand surgeons trained in orthopedic residencies were less likely to perform replantations than hand surgeons trained in plastic surgery residencies.12 This is likely because plastic surgeons are more adept at the microsurgical techniques needed for such cases. In areas where both groups claimed adequacy of training, such as operative basal joint treatment or cubital tunnel release, there were still differences in the likelihood to have performed these cases in the past 12 months, with orthopedic surgery hand surgeons
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performing them at a more frequent rate. This suggests that referral patterns are also an important factor in determining clinical case volume and variety. The main limitation of this study is that it is a self-reported survey. Selection and recall biases potentially limit the accuracy of the results. However, the response rate of 39 percent is quite good for a survey study such as this. The fact that the survey was distributed to American Society for Surgery of the Hand and American Association for Hand Surgery members is also important in limiting bias, as historically the American Society for Surgery of the Hand has a higher proportion of orthopedic surgery hand surgeons and the American Association for Hand Surgery has a higher proportion of plastic surgery hand surgeons. Our response rate of 76 percent orthopedic surgery hand surgeons and 24 percent plastic surgery hand surgeons is a very high representation of plastic surgery hand surgeons. For comparison, the percentage of Certificate of Added Qualifications plastic surgeons was 7.59 percent in 2007. In that same year, the percentage of plastic surgery hand surgeons in the American Society for Surgery of the Hand was 18 percent. When the data set is looked at as a whole, it is clear that differences in practice patterns between plastic surgery and orthopedic surgery of the hand exist. The average time in practice was 15.6 years for orthopedic surgery hand
Volume 135, Number 1 • Hand Surgery Clinical Practice Patterns surgeons and 16.2 years for plastic surgery hand surgeons, which demonstrates that these differences are persistent over time and experience. Differences in clinical exposure during training and referral patterns are likely contributors to ultimate practice patterns, although the relative contribution of each cannot be discerned from this data set. The type of fellowship training obtained appears to influence clinical cases more often performed by plastic surgery hand surgeons. It is likely that the perception of what a hand surgeon is by the population and by referring physicians has an impact on the disparities between plastic surgery and orthopedic surgery hand surgeons. Further investigation of these patterns will help shape fellowship training and reform.
CONCLUSIONS Despite being grouped under the subspecialty of hand surgery, plastic surgery residency–trained and orthopedic residency–trained hand surgeons exhibit significant variations in clinical practice patterns. Standardizing fellowship training may help even out some of the variances between orthopedic surgery–trained and plastic surgery– trained hand surgeons in future practice. Vishal Thanik, M.D. Institute of Reconstructive Plastic Surgery New York University Medical Center 307 East 33rd Street New York, N.Y. 10016
[email protected] references 1. National Resident Matching Program. Available at: http:// www.nrmp.org/wp-content/uploads/2013/09/resultsanddatasms2013.pdf. Accessed January 20, 2014. 2. Goldfarb CA, Lee WP, Briskey D, Higgins JP. An American Society for Surgery of the Hand (ASSH) task force report on hand surgery subspecialty certification and ASSH membership. J Hand Surg Am. 2014;39:330–334. 3. Bell RH Jr. Graduate education in general surgery and its related specialties and subspecialties in the United States. World J Surg. 2008;32:2178–2184. 4. Bell RH. National curricula, certification and credentialing. Surgeon 2011;9(Suppl 1):S10–S11. 5. Sachdeva AK, Bell RH Jr, Britt LD, Tarpley JL, Blair PG, Tarpley MJ. National efforts to reform residency education in surgery. Acad Med. 2007;82:1200–1210. 6. Sears ED, Larson BP, Chung KC. Program director opinions of core competencies in hand surgery training: Analysis of differences between plastic and orthopedic surgery accredited programs. Plast Reconstr Surg. 2013;131: 582–590. 7. Aliu O, Chung KC. A role delineation study of hand surgery in the USA: Assessing variations in fellowship training and clinical practice. Hand (N Y) 2014;9:58–66.
8. Higgins JP. The diminishing presence of plastic surgeons in hand surgery: A critical analysis. Plast Reconstr Surg. 2010;125:248–260. 9. Szabo RM. What is our identity? What is our destiny? J Hand Surg Am. 2010;35:1925–1937. 10. Noland SS, Fischer LH, Lee GK, Hentz VR. Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: A survey of program directors. J Hand Surg Am. 2013;38:760–765. 11. Noland SS, Fischer LH, Lee GK, Friedrich JB, Hentz VR. Essential hand surgery procedures for mastery by graduating plastic surgery residents: A survey of program directors. Plast Reconstr Surg. 2013;132:977e–984e. 12. Elliott RM, Baldwin KD, Foroohar A, Levin LS. The impact of residency and fellowship training on the practice of microsurgery by members of the American society for surgery of the hand. Ann Plast Surg. 2012;69:451–458.
Appendix. Survey Designed to Assess the Clinical Practice Patterns of Orthopedic Surgery and Plastic Surgery Hand Surgeons A1. Survey Q1. Please specify which surgical residency(ies) you have completed: □ Orthopedic surgery □ Plastic surgery Q2. Did you complete a hand fellowship? ◯ Yes ◯ No Q3. Was it: □ Orthopedic based □ Plastic surgery based □ Combined Q4. Please specify how many years you have been a practicing hand surgeon: Q5. What is your practice type? □ Academic □ Private □ Other ____________________ Q6. What is your practice structure? □ Single practitioner □ Multiple partners □ Multispecialty □ Academic □ Other ____________________
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Plastic and Reconstructive Surgery • January 2015 Q7. What is your practice setting? □ Urban □ Rural □ Suburban Q8. In which region of the country are you located? ◯ New England (Me., N.H., Vt., Mass., R.I., Conn.) ◯ Mid-Atlantic (N.Y., Pa., N.J.) ◯ South Atlantic (Del., Md., D.C., Va., W.Va., N.C., S.C., Ga., Fla.) ◯ Midwest (Wis., Mich., Ill., Ind., Ohio, Mo., N.D., S.D., Neb., Kan., Minn., Iowa) ◯ South (Ky., Tenn., Miss., Ala., Okla., Texas, Ark., La.) ◯ West (Idaho, Mont., Wyo., Nev., Utah, Colo., Ariz., N.M., Alaska, Wash., Ore., Calif., Hawaii) Q9. Which type of hospital(s) are you affiliated with? □ Private □ Community □ Government owned Q10. Specify the highest trauma level of affiliated hospital: Q11. Where do you most frequently operate? □ Hospital □ Ambulatory surgical center □ Practice-owned operating room Q12. Where do you get most referrals? □ Emergency room □ Primary care physician □ Fellow colleague □ No relationship □ Other ____________________ Q13. What form of reimbursement do you accept (1 to 4, with 1 being most common)? ______ Out-of-pocket ______ Private Insurance ______ Medicare ______ Medicaid Q14. Roughly how many hand cases do you perform per year?
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Q15. What percentage of your practice consists of hand cases? Q16. How has your number of hand cases trended over the years? ◯ Significant increase ◯ Slight increase ◯ No change ◯ Slight decrease ◯ Significant decrease Q17. Is the amount of hand cases less than you would like? ◯ Yes ◯ No Q18. Why? □ Lack of referral □ Lack of demand □ Oversaturation □ Personal choice □ Other ____________________ Q19. Within the last 12 months, have you performed: □ Carpal tunnel release □ Trigger finger release □ Operative treatment of hand infection □ Ganglion cyst excision □ Closed reduction and percutaneous pin fixation/open reduction and internal fixation of phalangeal fracture □ Closed reduction and percutaneous pin fixation/open reduction and internal fixation of metacarpal fracture □ Open reduction and internal fixation of distal radius fracture □ Operative repair of carpal bone fracture/dislocation □ Repair nail-bed injury □ Flexor tendon repair □ Extensor tendon repair □ Nerve repair □ Cubital tunnel release □ Operative treatment of basilar joint arthritis □ Palmar fasciectomy for Dupuytren contracture □ Xiaflex injection for Dupuytren contracture □ Digital replantation □ Congenital hand Q20. Of the cases listed above, which do you wish your fellowship better trained you for?