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Practice is the repetition of an action to improve its quality1.

Our world is increasingly specialised. Large amounts of new information that is continuously produced means it is difficult to maintain expertise in wide fields. This has resulted in more specialised practice in medicine.

Specialism in medicine is not a new idea, the need has been debated for many years. The following is from the British Medical Journal Nov 12, 18812

the public-"the foolish people"-are described as partly responsible 
for specialism; and then, just below, we are informed, as if to complete 
this mass of contradictions, that "great names will often override 
specialism". but that, when it does so, "this is due to the fault or 
ignorance of the public, and has its reward".
persons practising specialisms 
that have so limited an area that it is quite impossible for any man, 
who is restricted to any one of them, to make an income, unless he 
does so by inducing his patients to pay him needless visits ; such, for 
example, as to touch his throat with something every day ; to turn the 
screw of his 'instrument for the back' two or three times a week; or 
to do something to the Eustachian tube with equal frequency". " But 
these", he says, " are mistakes". These are " worse than crimes, 
these blunders".

In modern orthopaedics, volume of a particular kind of work influences outcome. This has been studied in terms of volume of surgery1,4,5 as well as rehabilitation3. The evidence points to better outcomes from surgeons performing higher volumes of specific hospital procedures. 

In terms of Shoulder & Elbow surgery, many surgeons will be Fellowship trained. This is a period of 6-12 months spent with a specialist team that will provide advanced training in shoulder and elbow work. 

Complex procedures in this field i.e. shoulder replacements are performed less frequently than hip or knee replacements. The infrequency with which shoulder replacement is performed is concerning because low-volume providers may produce outcomes inferior to those of high-volume providers1.


  1. The distribution of shoulder replacement among surgeons and hospitals is significantly different than that of hip or knee replacement 
    Samer S. Hasan, Jordan M. Leith, Kevin L. Smith, Frederick A. Matsen
    Journal of Shoulder and Elbow Surgery 
    March 2003 (Vol. 12, Issue 2, Pages 164-169)
  2. Specialism in Medicine, Br Med J  1881;2:797-798, doi: 10.1136/bmj.2.1089.797
  3. Joint Replacement Rehabilitation Outcomes on Discharge From Skilled Nursing Facilities and Inpatient Rehabilitation Facilities 
    Gerben DeJong, Susan D. Horn, Randall J. Smout, Wenqiang Tian, Koen Putman, Julie Gassaway
    Archives of Physical Medicine and Rehabilitation 
  4. J Bone Joint Surg Am. 2004 Sep;86-A(9):1909-16. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement.  - Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E.
  5. Clin Orthop Relat Res. 2007 Apr;457:35-41. Orthopaedic procedure volume and patient outcomes: a systematic literature review. - Shervin N, Rubash HE, Katz JN