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Core to selecting a fellowship should be desire to expand intellectual, surgical skills
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Each November, orthopedic residents take the Orthopedic In-training Examination. After months of preparation, residents spend a Saturday morning answering 275 questions to not only assess their fund of knowledge, but also help residency directors understand their educational progress.
Orthopedic In-training Examination (OITE) scores are highly predictive of success on part 1 of the American Board of Orthopedic Surgery examination, and residents know the scores may also play a role in the ability to get competitive orthopedic fellowships, although many fellowship applications no longer require OITE scores. After the test is completed, PGY4 residents will shift their attention to attaining desired fellowships and PGY2 and PGY3 residents will sharpen their focus on fellowships and the area of subspecialization to apply for in the near future. For residents who seek the most prestigious fellowships, this process of concentrating on one orthopedic subspecialization occurs early in residency education.
Role of fellowships
Currently, almost 90% of orthopedic graduates complete at least one fellowship after residency, with a growing trend toward multiple fellowships completed in synergistic areas. The reasons for selecting a fellowship or multiple fellowships are many, but at the core of the decision should be residents’ desire to expand their intellectual and surgical skills in an area that drives their passion for improved competency and excellence in practice. Many other factors play a role, but these factors and how they impact the decisions of residents and program directors are often not in sync. With the financial impact of orthopedic fellowship training and physician workforce projections, many residents are influenced primarily by personal residency program experiences, influences of mentors and the advice of peers.
Other components require a careful consideration of strategy and intuition. When fellowship directors were asked about the most important criteria in the selection of applicants for interviews and then ranking the applicants afterward, the two most influential criteria were a letter of recommendation from the residency program director and a letter of recommendation from the subspecialty-specific staff member. This situation creates a psychological imbalance in the resident’s environment.
Anthony A. Romeo
Despite the era of open assessment and evaluations of faculty, residents know the potential consequences if they fail to do what is considered necessary to achieve a strong letter of support from residency directors and subspecialty staff members. This imbalanced relationship can affect many decisions, including work load beyond the regulated hours, research projects and academic commitments, authorship on papers and presentations, and personal time commitments beyond the usual work environment. Such concerns can affect residents throughout their entire residency training and may bias fellowship selection process toward nonobjective factors influenced by program faculty.
Objective resources
Many independent and relatively objective resources for the selection of colleges, medical schools and residency programs exist. However, this is not true for the nine subspecialty areas of orthopedics, with a total of 485 different programs offering more than 900 positions for less than 700 PGY4 residents, more than 100 international medical graduates and a small, yet increasing, number of PGY5 residents and graduates who apply for second fellowships. Many programs have incomplete information and little data for the comparison of programs in the same subspecialty. Accreditation from the Accreditation Council for Graduate Medical Education (ACGME) helps formalize the information provided in descriptive terms, but less than 60% of programs are ACGME-certified, with sports medicine, hand surgery and trauma leading the way.
Some subspecialities also have little oversight from the governing subspecialty society to manage the fellowship process. For example, there has been a steady decline in the number of applicants for shoulder and elbow fellowships, yet the number of fellowship programs and positions has increased. For 2015, 43 positions will be offered to 42 applicants, with 27 of the applicants having a medical degree from an U.S. medical school. Furthermore, only 14% of the shoulder and elbow programs are ACGME-accredited, and three of the more prestigious programs are responsible for 25% of the fellowship positions.
Job market and demand
Recent conversations with graduates of shoulder and elbow fellowship programs suggest that finding a job dedicated to shoulder and elbow surgery is rare, and most graduates are accepting positions best characterized as general orthopedic surgeon practice. While the American Shoulder and Elbow Society has not instituted post-fellowship surveys to better understand the job market and demand for shoulder and elbow fellowship-trained surgeons and value of the fellowship, they are components of the other subspecialties, such as orthopedic trauma. The leadership of the Board of Orthopedic Specialty Societies (BOSS) is likely to institute a broader approach to this issue so real data can be collected and used to educate program directors and fellowship applicants about the contemporary issues and opportunities in the rapidly changing health care marketplace.
Whether a new graduate considers a position in private practice or an academic or hospital-based practice, subspecialty fellowship training appears to be essential for the most attractive job opportunities. There is also a perception among many orthopedic residency and fellowship educators that, compared to previous graduates, the current 5-year residency model does not consistently meet the expectation of providing well-trained orthopedic surgeons who can successfully and safely begin practice at the completion of residency or demonstrate a competent skill set during fellowship. Many factors are involved, including the expansion of information and technology in orthopedics and residency training regulations that reduced work hours. The unintended consequence is less time to develop surgical skills and competency, so it has become reasonable to consider 1 additional year of training as part of the typical education for orthopedic surgeons.
Financial considerations also support the value of fellowship training. Completion of a fellowship opens more job opportunities and provides orthopedic surgeons the ability to develop a niche in the practice environment — one that may preserve a practice, despite continued competition from other surgeons and non-orthopedic health care providers. The return on investment also can be realized with increased income from direct patient care. Adult spine returns the earliest and most substantial financial return with shoulder and elbow, sports medicine, hand, and adult reconstruction yielding positive returns as well. Trauma has a neutral return, while foot and ankle and pediatrics have negative returns. In the past, when the working hours related to a pure trauma practice were part of the consideration, the return became a negative. However, the workplace for trauma surgeons is steadily changing. There has been a significant growth in non-level 1 trauma hospitals hiring multiple trauma fellowship-trained orthopedic surgeons to manage and improve the flow of patient care into the hospital. With multiple-skilled surgeons, the work hours are equitably divided and the past’s poor quality lifestyle issues can be mitigated for these specialists.
Changing mosaic
With the substantial shift toward more fellowship-trained surgeons, there has also been a substantial increase in the job opportunities in adult reconstruction, foot and ankle, trauma, and even sports medicine. Based on an aging population, fellowship training in adult reconstruction, spine, trauma and foot and ankle will continue to provide a wide selection of opportunities in the job market. If the goal is to advance surgical skills beyond residency education to the widest possible arena, then sports medicine and trauma fellowships may provide the broadest enhancement of skills across the entire spectrum of musculoskeletal care.
Many practicing orthopedic surgeons, fellows and residents looking for a job become aware of the changing mosaic of the orthopedic job marketplace. However, the information is often anecdotal and not well understood or considered by PGY3 and PGY4 residents who make decisions early on that affect the rest of their professional careers. The source of the information is usually senior residents who share their own personal stories, or fellows who are currently at the residency program and are looking for jobs. The BOSS should advance their leadership to improve the entire fellowship process, including the collection and distribution of data before and after a fellowship, as well as into the early years of practice so invested parties can make more informed decisions.
As the OITE is completed, residents will have a brief period of celebration followed by a renewed interest in fellowship education. Hopefully, the best choice for residents will be an area that enhances their education and provides a continued spark for their professional passion. If the residents love what they are doing, then it may not feel as much like work every day. This is important for job satisfaction, as the only guarantee in our professional work environment is change.
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Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosure: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.