Thirty-one (69%) of the 45 directors agreed that the fellowship interview process should undergo fundamental change. Asked about possible solutions to current complaints, 60% of the directors agreed that interviews should be conducted in a central location. Of the directors who thought fundamental change was needed, 59% indicated AAOS and other specialty societies together should lead the change in the fellowship interview process.
Both residents and program directors were given the opportunity to write in suggestions regarding how to improve the fellowship interview process. Suggestions were made by 85 (66%) of the 129 residents and 24 (53%) of the 45 directors (Appendix).
Discussion
Graduating residents are entering a health care environment in which they must be financially conscious because of increasing education debt and decreasing reimbursement prospects.3 Nevertheless, an overwhelming majority of residents delay entering practice to pursue fellowship training—an estimated opportunity cost of $350,000.3 Minimal attention has been given to the potential costs of the fellowship interview process.
Our study results highlight that time away from residency training, financial costs associated with the fellowship interview process, and disruption of the residency program are substantial. On average, residents applied to 19 programs, received 14 interview offers, attended 11 interviews, were away from residency training 11 days, and spent $5875 on travel. The great majority of both residents and program directors wanted changes in the current paradigm governing the orthopedic fellowship interview process.
It is reasonable to think that the number of days residents spend away on interviews would reduce the time available for education and patient care. Although unknown, it is plausible that residents of programs outside major metropolitan centers and residents who apply to more competitive fellowships may be forced to spend even more time away from training. Outside the focus of this study are the impact that residents’ absence might have on their education and the impact of this absence on the people who do the residents’ work while they are away.
Mean fellowship expense was similar to that reported by residents pursuing a pediatric general surgery fellowship ($6974) or a plastic surgery fellowship ($6100).11,12 Unfortunately, we were unable to determine if average cost is influenced by choice of fellowship specialty or location of residency program. Regardless, fellowship cost may impose an additional financial burden on residents. According to the Association of American Medical Colleges (AAMC), the median salary for PGY-4 residents was $56,380 in 2013. Therefore, on average, the fellowship process consumes more than 10% of a resident’s pretax salary. For perspective, this equates to more than $40,000 for a practicing orthopedic surgeon with a median salary of $413,000.13 With an average medical student graduate debt of $175,000 and continuing decreases in reimbursement, further financial hardships to newly graduating residents cannot be understated.5,11,12
Almost 70% of program directors thought the fellowship process significantly disrupted their program. Reasons given for this disruption mainly involved residents’ time away from the program and the resulting strains placed on maintaining adequate coverage for patient care. The overall disruption score of 7.4 out of 10 was consistent with the great majority thinking that the fellowship process negatively affects their residency program. Altering the fellowship interview process may provide unintended benefits to programs and program directors.
Both program directors and residents communicated that change is needed, but there was little consensus regarding how to effect change and who should lead. This lack of consensus highlights how important it is for the various orthopedic leadership committees to actively and collectively participate in discussions about redefining the system. It has been proposed that it would be ideal for the AOA to lead the change, as the AOA consists of a representative cohort of academic orthopedists and leaders across the spectrum of all fellowship specialties.14 Given the abundant concern of both residents and program directors, we find it prudent to issue a call to arms of sorts to the AAOS and the individual orthopedic subspecialty societies to work together on a common goal that would benefit residents, programs, and subspecialties within orthopedics.
In trying to understand the challenges that residents, program directors, and programs face, as well as the inherent complexity of the current system, we incorporated respondents’ write-in comments into suggested ways of improving the fellowship interview process. These comments had broad perspectives but overall were consistent with the survey results (Appendix).
Technology
Health care is continually finding new ways to take advantage of technological advances. This is occurring with the fellowship interview schema. Numerous disciplines are using videoconferencing platforms (eg, Skype) to conduct interviews. This practice is becoming more commonplace in the business sector. In a recent survey, more than 60% of human resource managers reported conducting video interviews.15 Two independent residency programs have used video interviews with mixed success.16,17