Letter to the Editor Free

The International Orthopedic Surgery Fellow: The Beginning of the End

Shafic A. Sraj, MD

The author has no relevant financial relationships to disclose.

To the Editor:

I recently learned that the Accreditation Council for Graduate Medical Education (ACGME) has issued new ACGME Program Requirements for Graduate Medical Education that will go into effect July 1, 2016. The changes pertinent to orthopedic surgery residencies and fellowships were recently shared and discussed with the corresponding program directors in preparation for their implementation. One major change that will go into effect is the restriction of fellowship positions to graduates of ACGME-accredited residency programs, and Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or The College of Family Physicians of Canada (CFPC)-accredited residency programs located in Canada.1 Exceptions are allowed and may be granted by the review committee for exceptionally qualified applicants on assessment of the program director and fellowship selection committee and subjected to the approval of the applicant’s exceptional qualifications by the graduate medical education committee.

Having been on the receiving end of this requirement, I see several disadvantages that may undermine the benefits of restricting fellowship training to ACGME-accredited residents. This restriction may show a negative effect on the following 3 levels:

The Applicant. Subspecialty fellowship training is popular among international medical graduates (IMGs)—graduates of non-ACGME orthopedic residency programs by default. There were 445 fellows enrolled in orthopedic surgery subspecialties in 2012.2 Many of them return to their countries of origin, while a few stay and practice orthopedics in the United States. International medical graduates who seek entry into US graduate medical education programs must obtain an appropriate visa that permits clinical training activities. One popular visa is the J-1 visa. The Educational Commission for Foreign Medical Graduates (ECFMG) is the official entity authorized by the US Department of State to sponsor J-1 physicians to enroll in accredited programs of graduate medical education.3 Restricting enrollment in accredited fellowship programs is practically a denial of fellowship training for the vast majority of IMGs.

The Fellowship Program. The Table summarizes the orthopedic residency and fellowship positions filled across the United States in 2012.2 I sorted the numbers by IMG participation. The Table shows that while IMG residents constituted no more than 2.4% of the total orthopedic resident population, IMG fellows held an average of 13.7% of fellowship positions, and as high as 35.5%. Once the new requirement goes into effect, a few of the fellowship programs may have a difficult time filling their positions.

Orthopedic Surgery Residents, Fellows, and International Medical Graduates Enrolled in 2012


Orthopedic Surgery Residents, Fellows, and International Medical Graduates Enrolled in 2012

The Physician Work Force. International medical graduates make up one-fourth of the US physician work force, and they constitute a much bigger portion in the rural United States.4 To obtain a full license to practice medicine, the provider has to complete a minimum of 2 years of postgraduate training in an ACGME-accredited program. While this may be taken for granted by the ACGME resident, it is 2 or 3 ACGME-accredited fellowship years for IMGs. Denying access to accredited orthopedic fellowship programs will, in effect, prevent IMG orthopedic surgeons from practicing in the United States and thus impact musculoskeletal health in the rural United States.

I am an IMG who completed a non–ACGME-accredited residency program outside the United States and Canada. This new fellowship eligibility requirement would have prevented me from pursuing fellowship training in the United States, and I would not have been practicing orthopedic surgery in the rural United States.


  1. Accreditation Council for Graduate Medical Education. http://acgme.org/acgmeweb/tabid/140/ProgramandInstitutionalAccreditation/SurgicalSpecialties/OrthopaedicSurgery.aspx. Accessed April 9, 2014.
  2. Brotherton SE, Etzel SI. Graduate medical education, 2012–2013. JAMA. 2013; 310(21):2328–2346. doi:10.1001/jama.2013.278364 [CrossRef]
  3. Educational Commission for Foreign Medical Graduates. http://www.ecfmg.org/evsp/index.html. Accessed April 9, 2014.
  4. Educational Commission for Foreign Medical Graduates. http://www.ecfmg.org/about/index.html. Accessed April 9, 2014.

Orthopedic Surgery Residents, Fellows, and International Medical Graduates Enrolled in 2012

2012 ACGME-Accredited Residents/Fellows Total No. Enrolled IMG
No. %
Orthopedic residents 3501 83 2.4
Foot and ankle orthopedics 8 0 0.0
Orthopedic trauma 17 1 5.9
Hand surgery 111 7 6.3
Musculoskeletal oncology 12 1 8.3
Orthopedic sports medicine 188 18 9.6
Adult reconstruction 42 12 28.6
Pediatric orthopedics 36 11 30.6
Orthopedic spine surgery 31 11 35.5
Orthopedic fellows 445 61 13.7


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