by Michael Galvez, MD (@MichaelGalvezMD) and Adnan Prsic, MD (@Adnan_PrsicMD)
Dr. Sterling Bunnell, the “father of hand surgery”, introduced the concept of bringing together several surgical specialties to take care of all the tissues of the hand and upper extremity in order to repair and reconstruct all necessary structures in a coordinated fashion. If you value this ideal then the field of hand and upper extremity surgery may be the field for you!
Why Become a Hand Surgeon (in Addition to Being a Plastic Surgeon)?
Similar to the field of plastic surgery, the field of hand surgery encompasses an incredible breadth and therefore additional training is warranted. Likewise, the field encompasses a variety of practice settings including academic, private and group practices. Depending on the practice setting you will encounter hand trauma from replantation to mangled extremities, microsurgery, congenital hand differences, arthritis surgery, reconstructive wrist surgery, peripheral nerve surgery just to name a few. To become a hand surgeon, one must complete either an orthopedic, plastic or general surgery residency and then complete an additional one year fellowship in hand and upper extremity surgery. Aside from eventually become board certified in their primary board, hand surgeons must also obtain a Certification in the Subspecialty of Surgery of the Hand. Given that this is a challenging and rewarding specialty,1 it is not surprising that it is a competitive process.2
How can you show that you are uniquely interested in hand surgery? First make sure to explore all of plastic surgery and ensure that your interests gravitate to hand surgery. Which cases fascinate you? Do you enjoy the basic bread and butter cases and the incredibly complex? The best way to know early on is by performing as many hand surgery cases as you possible can as a junior resident. Given the complexity the upper extremity and the mechanics it is integral to understand the anatomy. Does hand anatomy excite you? If so, you should consider it further.
Although hand call can be a good way to experience hand surgery it certainly is tasking given the sheer volume of fingertip injuries and hand infections, but remember that this is just as small part of a career in hand surgery. When you are on other services, look at the OR schedule of the hand surgery service to find interesting cases to see. Meet with hand surgeon mentors at your institution to decide if this field is the correct fit for you. Consider starting research projects early in residency and present them at hand specific meetings (ASSH, AAHS, and your local hand society ex. New England Hand Society etc.)
The Process of Applying and Interviewing
The hand and upper extremity fellowship application is overall quite similar to applying to residency, except this time you will be in the trenches of your surgical residency.
The application process starts in September of your second to last year of residency (for example PGY-5 in a program that finishes after six years of residency). However, preparation starts a few months earlier.
- Save up vacation time for interviews and plan ahead.
- Start updating your CV and drafting your personal statement.
- Identify your needs for further training and identify programs that would offer you this. (Speak with your mentors, attend hand meetings and meet current fellows.)
- Identify three to four letter writers (chief of department, hand surgeons or research mentors), meet with them and ask them to support your candidacy by writing a letter. (Do not wait until last minute. Give the authors at least 3 weeks to complete your letter).
- Prepare applications (hopefully they will be online soon).
- Share information with your plastic surgery colleagues.
If you are prepared, then just like anything else it is possible and a rewarding experience. Similarly, to what our colleague Dr. Justin Broyles detailed (Tips for Financing the Plastic Surgery Interview Trail), this process can also get quite costly and require time off from residency. Make sure to coordinate days off well ahead and notify your service and attendings. Despite these challenges, the process was all worth it. There are some amazing programs out there with outstanding faculty that are looking for the best and brightest applicants.
Where Do I Apply To?
The American Society for Surgery of the Hand (ASSH) has a list of hand fellowships that one can apply to.3 But honestly it is difficult to tell which programs you can and cannot apply to. Why would that be? Well, some programs only accept orthopedic residents. Others only accept plastic surgery residents or a combination of both with specific spots reserved for either type of resident (for example at MGH and Stanford). Most are equal opportunity. Overall the most difficult aspect to navigate are what the specific application requirements are for each program, which can include the universal application, CV, photo, transcripts, copy of your medical school diploma, medical school dean’s letter, etc. The best approach is to search the program’s respective website for information, however they can sometimes be quite outdated.4,5 Contacting the program may be the safest choice.
How Many Programs Should I Apply and Interview At?
This is an individual question that you should ask your program director and will likely depend on the overall strength of your application. Most plastic surgery applicants apply to 10-20 programs, however some orthopedic surgery residents will apply and interview at several more.6 You can find when hand surgery interview invitations are offered on an orthopedic forum (orthogate.com) and under the topic orthopedic surgery fellowship forum.
Which Program is the Right Fit for Me?
There are several variables to consider. These include: operative experience, mentorship, rotation schedules, number of fellows, on-call requirements, didactic instruction, research interests, pediatric experience, geographical location, and more. Remember that although orthopedic shoulder surgery training may be interesting, you are unlikely to have a future practice that will encompass this. Additionally, your residency hand surgery experience may also guide you in which fellowship would complement (add onto) your skill set. Although programs may emphasize clinical areas that are stressed in their respective fields of orthopedic or plastic surgery, frequently it is recommend to obtain a strong component of both.7
Once you have interviewed, the next step is the match process. The Combined-Musculoskeletal-Hand Surgery Matching Program (CMMP) is administered by the National Resident Matching Program (NRMP) and occurs at the end of May of each year. This past year (2016) for appointment in 2017, the total programs were 83 with 174 available positions. Remember the anxiety right before the match for Plastic and Reconstructive Surgery? You will have that same anxiety during this process too!
Hand surgery is an amazing field. Good luck in the process!
- Why I Am Thankful to be a Hand Surgeon – JHS Focus. http://jhsfocus.org/2016/12/02/why-i-am-thankful-to-be-a-hand-surgeon/. Accessed December 3, 2016.
- Results-and-Data-SMS-2016_Final.pdf. http://www.nrmp.org/wp-content/uploads/2016/03/Results-and-Data-SMS-2016_Final.pdf. Accessed December 3, 2016.
- Fellowship Programs. http://www.assh.org/For-Physicians/Get-Involved/Fellowship-Programs. Accessed December 3, 2016.
- Silvestre J, Guzman JZ, Abbatematteo JM, Chang B, Levin LS. Evaluation of content and accessibility of hand fellowship websites. Hand N Y N. 2015;10(3):516-521. doi:10.1007/s11552-014-9732-9.
- Trehan SK, Morrell NT, Akelman E. Accredited hand surgery fellowship Web sites: analysis of content and accessibility. J Hand Surg. 2015;40(4):778-782. doi:10.1016/j.jhsa.2015.01.024.
- Meals C, Osterman M. The hand surgery fellowship application process: expectations, logistics, and costs. J Hand Surg. 2015;40(4):783-789. doi:10.1016/j.jhsa.2014.12.041.
- 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(3):582-590. doi:10.1097/PRS.0b013e31827c6f54.