Thursday, April 9, 2015

The Orthopedic Surgery Fellowships

I recently occupied the attention of some knee surgeons, with whom I had interacted in a very different way when writing about how fellowship matches might be implemented for orthopedic surgeons (Harner, Christopher D., Anil S. Ranawat, Muriel Niederle, Alvin E. Roth, Peter J. Stern, Shepard R. Hurwitz, William Levine, G. Paul DeRosa, Serena S. Hu, "Current State of Fellowship Hiring: Is a universal match necessary? Is it possible?," Journal of Bone and Joint Surgery, 90, 2008,1375-1384.)

So I read this state-of-the-match report with interest...

Orthopedic Surgery Fellowships: The Effects of Interviewing and How Residents Establish a Rank List

Matthew C. Niesen, MD; Jeffrey Wong, MD; Edward Ebramzadeh, PhD; Sophia Sangiorgio, PhD; Nelson Fong SooHoo, MD; James V. Luck, MD; Jeffrey Eckardt, MD
March 2015 - Volume 38 · Issue 3: 175-179

"Prior to the establishment of the Orthopaedic Fellowship Match in 2008, orthopedic residents had to decide where to complete fellowship training in an environment without a formal match system.1 Annual meetings were “free-for-alls” with both programs and residents anxious to make a deal. If interviews occurred, they were uncoordinated and happened earlier and earlier in the process as programs competed for top candidates and residents tried to secure positions at the best programs. Often, both sides involved in the process had to make a decision without knowing what alternatives might exist or arise in the future. Residents frequently were uncertain whether they would receive additional offers and were pressured to commit to a fellowship, while fellowship programs had high interview cancellation rates because residents had already taken other positions. This system may have caused residents and fellowship programs to settle for a less than ideal “match.” A 2008 American Orthopaedic Association symposium indicated that more than half of all residents surveyed accepted their first fellowship offer. The same survey showed that 78% of residents favored a transition to a centralized match.2
One of the primary goals of the Orthopaedic Fellowship Match was to create a fairer and more coordinated process in which both applicants and fellowship programs had time to evaluate and consider their training options. However, with the establishment of the match, new complications arose. Fellowship programs require additional planning for interviewing and ranking a large number of residents, residencies need to find coverage for residents away from their clinical duties, and residents face the additional issues of cost and time away from service. The magnitude of these factors is currently unknown. A primary goal of this study was to establish benchmark values for these factors and to quantify the financial impact and time away from service, specifically for residents. This information will be valuable to residents and both residency and fellowship programs as they complete the fellowship match process.
After applying to and interviewing for fellowships, residents have the task of establishing a final rank list. Several studies have identified the factors medical students in the United States and Canada consider most important when establishing a rank list for residency positions.3–5 The factors that are commonly ranked the highest for residency positions include clinical experience, location, and academic reputation. After a brief review of the literature, it is apparent that limited data exist identifying what factors are most important for residents of all specialties in medicine and surgery when choosing a fellowship program or establishing a rank list. A recently published study evaluated what factors residents pursuing pediatric otolaryngology positions considered to be most important when establishing a rank list for fellowship positions.6For these applicants, appropriate experience, faculty reputation, and location were ranked as the most important factors when choosing a program. Accreditation Council for Graduate Medical Education (ACGME) accreditation, fellowship longevity, and salary were less important. The factors orthopedic surgery residents consider most important when establishing a rank list for fellowships have not been investigated. Thus, this was a second goal of this study.


The Orthopaedic Fellowship Match has created an environment in which residents can consider a greater number of options without feeling pressure to make a quick decision. The vast majority, nearly 96%, of orthopedic surgery residents pursue fellowship training; sports medicine, hand, and adult reconstruction were the most popular subspecialties in this study. The interview process has financial implications and draws residents away from clinical services. The estimated cost of the orthopedic fellowship interview process was $4671±$2454, with a median of 10 days off service required to interview. These are the first benchmark values established for these variables.
Residents should attempt to be more selective with their application choices to minimize unnecessary costs, time off service, and associated stress and fatigue. Finally, this study is the first to demonstrate what factors orthopedic surgery residents consider most important when establishing a final rank list for fellowships. Residents value operative experience, autonomy, and fellowship staff members the most and place the least importance on research opportunities and salary. Fellowship programs may find this information useful as they choose which aspects of their programs to highlight during recruitment activities.

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