Over the past several decades, an increasing number of orthopedic surgery residents have pursued fellowship training.1 This inclination parallels market trends toward subspecialization.2-5 In 1984, 83% of orthopedics job announcements were for general orthopedists. Twenty-five years later, almost 70% of orthopedic opportunities were for fellowship-trained surgeons.6 Further, between 1990 and 2006, the proportion of practicing orthopedic generalists decreased from 44% to 29%.3 In 2007, the American Academy of Orthopaedic Surgery (AAOS) reported 90% of graduating residents were planning to pursue fellowship training.7 Reasons for the explosion in subspecialty training are plentiful and well documented.2-5 Subspecialty positions now dominate the job market, further reinforcing incentives for residents to pursue fellowship training.
The past several decades have seen numerous changes in the orthopedic fellowship interview process. Early on, it was largely unregulated, dependent on personal and professional connections, and flush with the classic “exploding offer” (residents were given a fellowship offer that expired within hours or days). In the 1980s, as the number of fellowship applications surged, the Accreditation Council for Graduate Medical Education (ACGME) pushed for a more regulated process.8 To further standardize the system, the American Orthopaedic Association (AOA), the AAOS, and several other specialty organizations created the Orthopaedic Fellowship Match Program Initiative in 2008.9 Currently, all orthopedic specialties are represented in either the San Francisco Match Program or National Residency Match Program.
As the system currently stands, postgraduate year 4 (PGY-4) residents are required to interview across the country to secure postgraduate training. This process necessitates residents’ absence from their program, reducing educational opportunities and placing potential continuity-of-care constraints on the residency program. Despite the growing competitiveness for fellowship positions, the increasing number of fellowships available, the rising educational debt of residents, and the limitations of the 80-hour work week, the impact of the interview process on both residents and residency programs has received minimal attention.
We conducted a study to elucidate the impact of the fellowship interview process on residents and residency programs. We hypothesized the time and financial costs for fellowship interviews would be substantial.
Materials and Methods
We obtained institutional review board (IRB) approval for this study. Then, in April 2014, we sent 2 mixed-response questionnaires to orthopedic surgery residency directors and residents. There were 8 items on the director questionnaire and 11 on the resident questionnaire. The surveys were designed to determine the impact of the fellowship interview process on residents and residency programs with respect to finances, time, education, and continuity of care. Each survey had at least 1 free-response question, providing the opportunity to recommend changes to the interview process. The surveys were reviewed and approved by our IRB.
An email was sent to 155 orthopedic surgery program directors or their secretaries. The email asked that the director complete the director questionnaire and that the resident questionnaire be forwarded to senior-level residents, PGY-4s and PGY-5s, who had completed the fellowship interview process. Forty-five (29%) of the 155 directors responded, as did 129 (estimated 9.5%) of an estimated 1354 potential PGY-4s and PGY-5s.10
The Survey Monkey surveys could be completed over a 3-week period. All responses were anonymous. Using Survey Monkey, we aggregated individual responses into predefined clusters before performing statistical analysis. Descriptive statistics were generated with Microsoft Excel.
Results
Survey respondents represented all the orthopedic subspecialties (Table). Seventy-eight percent of residents applied to at least 13 programs (average, 19) (Figure 1). Ninety-two percent received at least 8 interview offers (average, 14). Eighty-three percent attended 8 or more interviews (average, 11). Seventy-one percent of all interviews were granted when requested, and 79% of all interviews were attended when offered.
Residents spent an average of $5875 (range, $500-$12,000+) on the fellowship interview process (Figure 2). The highest percentage of respondents, 39.5%, selected an average expense between $4000 and $6000. Forty-nine percent of residents borrowed money (from credit cards, additional loans, family members) to pay their expenses.
Average number of days away from residency programs was 11, with 86% of residents missing more than 8 days (Figure 1). About one-third of residents reported being away from their home program for almost 2 weeks during the interview season. Further, 74% of residents wanted changes made to the fellowship application process.
Thirty-seven (82%) of the 45 program directors were from academic programs, the other 8 from community-based programs. Average number of residents in programs per year was 4 (73% of the programs had 4-6 residents per year). Respondents rated the disruption caused by residents’ interview absences from 1 (least disruptive) to 10 (most disruptive) (Figure 3); the average rating was over 7 (high level of disruption). Although 9% of directors thought the process caused little or no disruption (rating, 1-3), 62% thought it extremely disruptive (rating, 8-10).
