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.6 For 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.
Materials and Methods
Certified exempt institutional review board status was obtained through the Office of the Human Research Protection Program at the University of California, Los Angeles. An anonymous, online, multiple-choice survey with 19 questions was distributed to postgraduate year (PGY)-4 and PGY-5 orthopedic surgery residents in the United States. Because orthopedic surgery residents’ email addresses are not readily available, orthopedic surgery program coordinators with publicly available email addresses were contacted twice, 1 week apart, and asked to request their residents’ participation. All senior residents were eligible to participate, including those who did not pursue fellowship training. A convenience sample was used. The survey was closed after 1 month for data analysis. All responses were included in the study analysis.
Descriptive statistics, including mean, median, and range, were calculated for each survey response using SPSS version 17.0 software (SPSS Inc, Chicago, Illinois). Boxplots were produced to present the distribution of responses, as appropriate, for interview process variables such as number of programs applied to and interviews offered as well as total cost of interviews. A histogram was produced for stress level.
Means and 95% confidence intervals were produced for 10 factors influencing fellowship selection that participants were asked to rank, both across specialties and as a function of specific orthopedic surgery specialties. Ten general linear models were produced, one for each ranking criterion, to compare the mean rankings of each criterion as a function of specialty. This was followed by the least significance difference method of multiple comparison methods to determine the P value for each pair of means among the specialties.
One hundred forty-nine orthopedic surgery residents, from 27 US states (78 PGY-4 [52%] and 71 PGY-5 [48%]), participated (Table). The response rate could not be calculated because there was no way to determine how many residents could be reached via email. An estimated 1277 PGY-4 and PGY-5 orthopedic surgery residents (11.6%) existed in the United States at the time of the survey.7 Ninety-six percent chose to pursue fellowship training, while 4% (6 respondents) chose not to pursue further training. Of those not pursuing fellowship training, 3 stated that they were going into general orthopedics, 1 had a military service obligation, 1 was undecided, and 1 had a mandatory 6th year of residency. Sports medicine was the most common specialty declared (26.8%), followed by hand (16.8%) and adult reconstruction (12.8%). Pediatrics (6.0%), shoulder and elbow (4.7%), and oncology (1.3%) were the least common specialties (Figure 1).
Characteristics of Participants
Breakdown of orthopedic specialty selected.
Residents applied to as few as 1 and as many as 48 fellowship programs. Respondents were each offered between 1 and 35 interviews, and each completed between 1 and 20 interviews (Figure 2).
When comparing responses by chosen specialty, some differences were observed. For example, sports medicine respondents submitted the largest number of applications (range, 7–48), followed by hand respondents (range, 5–35) and shoulder and elbow respondents (range, 10–30) (Table). In contrast, oncology and pediatrics respondents submitted the smallest number of applications (range, 11–14 and 8–15, respectively). Accordingly, sports medicine respondents were offered the largest number of interviews (range, 5–35 per respondent), followed by hand and shoulder and elbow respondents (range, 4–27 and 7–26, respectively). Furthermore, sports medicine, hand, and shoulder and elbow respondents also completed the most fellowship interviews (range, 3–19, 4–20, and 5–18, respectively, per individual applicant).
On average, residents spent $4671±$2454 (range, 0–$12,000) during the interview process and missed between 1 and 24 days of work (median, 10 days). Residents completed an average of 10±3.4 (range, 1–20) interviews.
Residents were asked to rank 10 listed criteria in order of importance for selecting a fellowship program and establishing a final rank list, with 1 being the most important factor and 10 being the least important factor. Regardless of specialty, respondents had similar priorities (Figure 3). The most important factors were considered to be surgical experience and autonomy (median rank, 2), followed by staff members (median rank, 3). Program prestige, number of cases, and satisfaction of past fellows each received a median rank of 4; location received a median rank of 5, facilities a median rank of 7, and call/rounding requirements a median rank of 8. The factors consistently ranked lowest were research resources and salary, each receiving a median rank of 9.
How residents ranked the importance of criteria for establishing a final fellowship program rank list, with 1 being most important and 10 being least important.
The Orthopaedic Fellowship Match has been successful in creating a more coordinated and fair process for both applicants and fellowship programs. This is supported by the authors’ finding that applicants are interviewing with 15 to 20 programs prior to submitting a final rank list. During this process, residents have the chance to consider a large number of programs and opportunities without pressure to make a quick decision. This process, however, brings new issues into the equation for all parties involved. The primary goal of this study was to quantify the estimated financial impact and the time away from service that the interview process presents for residents. The authors found an estimated cost of $4671±$2454 and a median of 10 days off service to complete the interview process. Residents completed an average of 10±3.4 (range, 1–20) interviews. Thus, the average cost per interview is approximately $467. This study is the first to establish orthopedic fellowship application process benchmarks.
The results of this study should be reviewed by residents when they are preparing to apply for fellowship. Data suggest that residents need only apply to 8 to 10 programs and interview with 7 to 8 programs for a match rate of 99%.8 Rather than applying to 20 to 30 programs, completing 10 to 20 interviews, and dealing with the financial impact, stress, fatigue, and time away from service this would require, residents can be more selective in the initial application process. This may require increased time spent researching programs and obtaining faculty and peer program recommendations based on knowledge or personal experience before deciding which programs to apply to in the first place. Orthopedic surgery residency positions in the United States are salaried, and residents do not incur a cost for time missed for interviews. However, by eliminating 2 to 3 programs from an interview list, residents may be able to save a significant amount of money and spend less time away from clinical duties. Updated, accessible, and accurate online information and websites will be vital for the success of residents in this process. However, recently published studies evaluating the accessibility and accuracy of online information and websites for orthopedic surgery sports medicine and pediatric fellowships concluded that most fellowships lack easily accessible or complete websites.9,10 The quality of online information and websites must be improved to assist residents as they research programs and determine where to apply. Other potential ways to improve the orthopedic fellowship match process include having a national interview week at one location or making videoconference interviews available, thereby reducing cost and time necessary for travel.
This study has provided the first examination of the factors orthopedic residents consider most and least important when establishing a fellowship rank list. For residents across all specialties, location, salary, and research opportunities were of little importance. When establishing a final rank list, surely the 1-year duration of most fellowships is a factor. This is in contrast to the importance given to location among medical students establishing a rank list for residency positions, as these programs last 3 years or more depending on the specialty area selected.11 Operative autonomy, program prestige, and staff at the fellowship were consistently regarded as the most important factors. These are similar to findings among residents pursuing fellowship positions in pediatric otolaryngology, as they also rated program prestige and clinical experience highly.6 This is not surprising; residents pursuing fellowship training in all specialties in medicine and surgery have a desire to train at the “best” programs and to learn from the “best” in their field. Orthopedic fellowship programs may want to focus on resident autonomy and operative experience during interviews in their effort to create more interest in their programs.
This study had several limitations. A response rate could not be calculated because the number of residents who received the email request to participate via their program coordinator could not be determined. According to data released in the 2012 National Residency Matching Program report, 1277 resident positions were filled in 2008 and 2009.7 If the current authors assume that all program coordinators in the United States were contacted and forwarded the email request to their residents, the response rate is 11.6%.
An additional limitation was that no information about residents’ qualifications for the fellowship positions was obtained, including factors such as examination scores and research experience. Residents with lesser qualifications may need to apply to and interview with more programs for a successful match. Residents were also asked to estimate the time away from service and the amount of money spent on the interview process. Recall bias existed because some residents completed the survey up to 1 year after the match process.
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.
- SF Match Residency and Fellowship Matching Service. www.Sfmatch.org. Accessed November 1, 2014.
- Harner CD, Ranawat AS, Niederle M, et al. AOA symposium: current state of fellowship hiring. Is a universal match necessary? Is it possible?J Bone Joint Surg Am. 2008; 90(6):1375–1384. doi:10.2106/JBJS.G.01582 [CrossRef]
- Blissett S, Law C, Morra D, Ginsburg S. The relative influence of available resources during the residency match: a national survey of Canadian medical students. J Grad Med Educ. 2011; 3(4):497–502. doi:10.4300/JGME-D-11-00043.1 [CrossRef]
- Nagarkar PA, Janis JE. Fixing the match: a survey of resident behaviors. Plast Reconstr Surg. 2013. Epub ahead of print. doi:10.1097/PRS.0b013e31829ad2bb [CrossRef]
- Love JN, Howell JM, Hegarty CB, et al. Factors that influence medical student selection of an emergency medicine residency program: implications for training programs. Acad Emerg Med. 2012; 19(4):455–460. doi:10.1111/j.1553-2712.2012.01323.x [CrossRef]
- Chun R, Preciado D, Brown DJ, et al. Choosing a fellow or fellowship: a survey of pediatric otolaryngologists. JAMA. 2014; 140(2):102–105.
- National Resident Matching Program. www.nrmp.org. Accessed November 1, 2014.
- American Academy of Orthopaedic Surgeons. Pursuing an orthopaedic fellowship. http://www.aaos.org/news/aaosnow/sep11/clinical1.asp. Accessed November 1, 2014.
- Davidson AR, Murphy RF, Spence DD, Kelly DM, Warner WC Jr, Sawyer JR. Accessibility and quality of online information for pediatric orthopaedic surgery fellowships. J Pediatr Orthop. 2014; 34(8):831–834. doi:10.1097/BPO.0000000000000217 [CrossRef]
- Mulcahey MK, Gosselin MM, Fadale PD. Evaluation of the content and accessibility of web sites for accredited orthopaedic sports medicine fellowships. J Bone Joint Surg Am. 2013; 19:95(12).
- Wang T, Wong B, Huang A, et al. Factors affecting residency rank-listing: a Maxdiff survey of graduating Canadian medical students. BMC Med Educ. 2011; 11:61. doi:10.1186/1472-6920-11-61 [CrossRef]
Characteristics of Participants
|Characteristic||No.||Median (SD) No. of Programs Applied to|
| 4||78||17.0 (17.7)|
| 5||71||16.5 (9.0)|
| Sports medicine||40||23.5 (9.2)|
| Adult reconstruction||19||14.0 (5.7)|
| Foot and ankle||12||14.5 (5.7)|
| Hand||25||20.0 (7.3)|
| Shoulder and elbow||7||20.0 (8.2)|
| Oncology||2||12.5 (2.1)|
| Pediatrics||9||13.0 (2.1)|
| Spine||12||13.5 (8.8)|
| Trauma||17||15.0 (7.7)|
| No fellowship||6||Not applicable|