Is Fellowship for Me?

Introduction

Pursing postgraduate training is a very important decision in a surgeon's training. This process is time consuming, frustrating, difficult, and expensive-yet very exciting. The training starts a surgeon's personal goal of practice specialization. This period of training needs to be carefully understood because there are many different forms of post-graduate training available.

A fellowship usually designates a period of training which includes specific academic requirements. While there have been fellowships of six months' duration, to be accredited they must now be a minimum of twelve months. A preceptorship is a period of training, which is more informal and is not usually subject to the same academic requirements. A preceptorship also does not afford the formal recogni-tion of a level of training.

Because this is a very expensive process, it is financially important to make sound decisions. Applications alone will easily cost $200. Each inter-view trip costs between $600 and $1000, depending on distance traveled, availabil-ity of discount airfares, time available for advance planning, etc.

This information is provided by the American Academy of Orthopaedic Surgeons' Committee on Candidate Member Services to allow an overview of the process of selecting, applying for and choosing post-graduate training. It is hoped that this information will be of benefit to residents involved with this process. The committee welcomes any comments about this material.

Area of Interest

The first selection factor should be an area of orthopaedics that you enjoy. Obviously if this is going to be the core of your practice, it should be in a thoroughly enjoyable area that fascinates you. If a specific area does not have this "draw," you may not be happy practicing in a more narrow area of orthopaedics, and perhaps you should consider a general practice.

Subspecialization

The fellowship process is designed to allow physicians to develop special skills and interests that they hope will become the focus of their professional career. With orthopaedics being so diverse a specialty, many surgeons like to focus their atten-tion on a narrower area. They feel that this allows them to obtain a higher level of proficiency and knowledge about a more limited area of practice-and thus they can provide better care for their patients in that area.

How should the area of a fellowship be selected? An easy way to start is by reviewing the available areas of fellowship listed in the Directory of Graduate Medical Education Programs (the "Green Book"), from the American Medical Association (800-621-8335) which lists all the requirements for training programs and all the accredited residencies and fellowships. This information is available online. Another source of information is a yearly fellowship listing Post-Graduate Orthopaedic Fellowships, published by the Academy.

Marketing

In today's world of group practices, many residents feel that they need a "niche" to be selected by a specific group. Some residents perceive this "niche" as fellowship training, which allows them and the group to have an "edge" over other groups in town. It is true that some practices will recruit with an eye towards trying to market a subspecialty service that other offices in town do not offer. But in spite of a desire to offer something different to the community, the primary factor in making a fellowship choice should still be your personal interest.

Community Needs

A final consideration should also be the needs of society. If a community al-ready has a good supply of orthopaedic surgeons practicing a subspecialty, will the community benefit by another one?. What about the changing demographics of our society? What type of subspecialist will be needed in 10 or 20 years to handle the needs of society at that time? How are the technological advances that are being made in orthopaedics affecting the patient demand for various services? Is society willing to support the demand for very specialized and highly technical advances -or will the inability of society to pay for these services cause their utilization to drop?

Geography

Everyone has an idea about his or her favorite climate. Fellowship may be a good opportunity to see if you really like a certain climate as much as you have thought you would. Will someone who grew up in Minnesota really like the warmth of Ari-zona--or will you miss the beauty of fall and the crunch of the snow? If on the other hand, you are from Texas and absolutely hate the snow and cold, don't go to Vermont!

You probably will be unhappy and it will reflect in your work. Com-ments on how much you dislike the climate may be interpreted as unhappiness with your program. Choose a spot where you will be comfortable living.

Family

A very important factor to consider is obviously family-both yours and your spouse's or companion's. Depending on the relationships involved how close to or how far away from family you will be may be very important. The health of family members and the potential for emergency trips may be very significant.

Future Practice Areas

Another factor in this decision may be where you are thinking about locating your practice after your fellowship. A fellowship generates a great deal of exposure to the local staff and creates many networks. Many residents decide to stay in the vicinity of their fellowship for this reason. However, areas with strong fellowships also usually have an ample supply of those subspecialists for this reason also, which makes the area more competitive.

Something Different

Some people find the opportunity to spend a year in a geographic location they wouldn't normally live in to be quite attractive. Spending a year in England or Switzerland while obtaining advanced training may be an experience that you'll remember for a lifetime. Some close friendships that will be treasured can also be established in this situation.

Training

Having narrowed your choices by subspecialty and geographic area, consideration must now be given to the attributes and qualities of the individual programs. How can a logical decision be made to find the program that best fits your needs? Several factors need to be assessed.

Teaching Institution vs. Private

A fellowship program closely associated with a residency at a teaching hospital may allow wider contact, more opinions and an increased emphasis on formal teaching, conferences, professional interaction. A private fellowship offers a close personal relationship with the director and the opportunity to learn a method in depth. Which type of fellowship would best suit your needs?

Unfortunately there are still some fellowships that look upon the fellow as a physician's assistant and a method to increase the patient (dollar) volume of an office. When you are operating, will your director be there with you, teaching you?. When you are in clinic, will your director be there also? Will you ever have the opportunity to formulate and carry out your own patient care plan-or, because all the patients are "private patients," will you be able only to observe the plan of the director? If the director is on vaca-tion or at a meeting, what happens to your teaching? How much time is the director gone from the program? How many staff will be involved with your training? How many other fellows/residents are in the program, and is there sufficient clinical volume to give the experience you desire to everyone taking a fellowship?

Accreditation

Is the fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME)? If not, are there efforts being made to accomplish this? Most fellowships must last 12 months to be accredited. The accreditation process was instituted to assure the applicant that a certain mandated level of training was available at a certified program. Currently there are eight areas in which fellowships are accredited: hand, trauma, pediatrics, sports medicine, oncology and pathology, arthritis and reconstructive surgery, foot and ankle and spine. See this site to determine the status of programs you may be considering.

Operative vs. Cognitive

What is the type and magnitude of the experience this fellowship offers? Is it operative or cognitive? If you have just finished a very surgically intense residency and haven't had the time to sit down and sort out all your experiences, perhaps you should consider a "thinking fellowship". If conversely you have not done much operating in your residency, you should look for a fellowship with heavy operating experience to hone your surgical skills. Cognitive skills must be maintained and developed. Surgical case load is not the all-encompassing factor that makes a program good. The development of thought patterns and approaches to problems are the most important benefit you will gain from a fellowship.

Research

Is research a required part of the fellowship? Some research is a good aspect of fellowship and is generally a requirement for accreditation. But how will the research be done? Will there be time set aside each week or will it be a month-long block? How is the research project selected? Is it clinical or basic science? Do you get to work on your own project that you selected according to your interests, or do you work for two months on the continuing project of the director that each of the last 10 fellows has contributed two months of work to?

Work Schedule

What will your work week be like? Are you in a clinic on certain days, the O.R. on others, and the office still others? What is the balance between O.R., clinic, office, studying, research, reading and family? Will you be expected to do all the history and physicals, discharge summaries, progress notes and dressing changes, or is there ancillary help to do these chores? What is expected of the fellow-are you supposed to be in clinic seeing patients while the director is operating to in-crease the operative load of the director? Is the fellow expected to staff the residents in surgery?

Case Load

The surgical experience of a fellowship needs to be broad and varied. Even if you don't plan to do congenital hand, a hand fellowship needs to expose you to some congenital hand as well as rheumatoid, traumatic and reconstructive. A fellowship is already a subspecialization-don't further subspecialize before you have even gotten into the area. The surgical experience also needs to be of suffi-cient magnitude to develop the manual skills needed for the discipline. Obviously, your surgical skills will improve even after your fellowship, so don't feel that they must be fully developed when you finish your fellowship.

Fellow/Resident/Staff Relationships

What is the relationship between the fellow and the residents? Will the fellow potentially be taking cases away from the resident? Have the residents felt previous fellows to be a threat to their training? Prior to going for an interview, a phone call to the residents and former fellows is very helpful and may potentially save you hundreds of dollars in interviewing costs.

Is the fellowship director so busy that the fellow opens and closes cases-while the staff person does the case? Is the fellowship director a teacher? Can the fellowship director explain the reasoning and science of patient management decisions, or is the teaching method simply, "Do it like I do it and don't ask any questions?" Is the fellowship director a "big name" and always on the road so that the director isn't the one you will get your training from? Is there time to sit and talk about what is happening with the cases? Is the personality of the fellowship director a type that you can be comfortable with?

What is the teaching role of the fellow? Are you expected to teach and educate the residents? What are the duties of the fellow? Was a fellowship a way to get cheap labor for the office rather than pay a more expensive salary for a physician's assistant?

Future Practice Considerations

If prior to starting your fellowship, you already have decided to locate in a particular city, a fellowship may be a useful tool to help "scout" potential practice opportunities in the area. Also, it may be very helpful in becoming known to the community, so that you can quickly develop a referral base when you begin to practice.

While some fellows have become partners with their fellowship directors, and some directors have recruited residents to be their fellows with an eye toward their becoming future partners, it would probably be unwise to select a fellowship with the thought that you could become a partner of the director, "if they just see how hard a worker I am." Also, such a tangential reason for choosing a fellowship can become problematic if you decide not to become a partner, for whatever reason. What will the reference letters from the fellowship director state? What is the track record for the office have there been several previous fellows who have been made associates and worked for several years, only to then be declined partnership? If you are made a partner, will you always remain "hidden" by the director and never allowed to fully "mature" to your own full potential? While practice with a fellowship director may be an exciting possibility, if everyone in the office is trained exactly the same way, how do you grow after the fellowship? Will you always remain a "fellow" in the eyes of the director and never really become a partner/equal?

Occasionally, you know the particular practice you will be associated with upon completion of the fellowship. Commonly they want you to have a particular area of expertise, and have requested that you take training in that particular area. In such a situation, it may be possible to obtain some funding from the practice to help you through the fellowship year.

Application Process

The entire endeavor of fellowship begins with the application process. This is a stressful, difficult procedure that can be very expensive. It may have many pitfalls. They are very simple to avoid, but need careful attention.

Applications

Accredited Fellowships participate in the Match through the National Resident Match Program details can be found on their web site.

In general, applications will be due in the fall of the PGY-4 year. You need to start sending for the materials in the summer between the PGY-3 and PGY-4 year. A good application takes time to prepare, so make sure you start this process early. As a practical matter, most applicants cannot complete more than 15 or 20 applications. All applications must be typed. A handwritten application filled in late at night does not portray a highly professional person, and given five equally qualified applicants, the appearance of the application may be a subtle influence against your selection. The director will not "understand" that you were on call all week and were pushing to get the application finished when you spilled the coffee on it. It is assumed all the applicants were also on call and also pushing to finish their applications. You want your application to be

  • complete
  • neat
  • legible
  • on time
If you want to be considered for a position, you must be aware of the deadlines for that position, and they vary with each program. Follow the directions exactly and fill out the complete application according to the requested format. Do not use the short cut of "see personal statement," when the statement does not answer the question or provide the exact information requested. A simple way for a director to sort out applicants is to cut all applications that are not complete at the deadline or do not follow the directions. It can be reasoned that the applicant who does not pay attention to the rules for applying to the program is unlikely to pay attention to the rules in the program or the needs of the patients.

Photographs

Photographs cannot be required on applications. If the program requests a photograph, and you choose to send one, be sure it is recent, is a good likeness, and portrays you as a professional. A photograph is helpful for the program director to recall you after the interview.

OITE Scores

How about OITE scores? A similar reasoning applies. Directors cannot require you to disclose your OITE scores, but they can ask, and if you elect to voluntarily disclose them, then you provided the information, which is your privilege. If your scores are not the highest, that is okay. Provide the scores and explain why they are not indicative of your abilities. Better yet, have your chairman's letter of recommendation state that you perform better than your scores would indicate. Not providing the scores or arguing with the director that OITE scores are not to be used for this purpose gives the impression that they are very bad. Average scores are just that-average, and easily balanced with reference letters.

Reference Letters

Reference letters are a crucial part of the application process. Because it is the applicants who ask people to write reference letters, it is expected that they would ask only those who would write favorable reference letters. Therefore, almost every letter the director will receive on every candidate will describe the candidate as being able to walk on water. It is unlikely that every candidate is as outstanding as the usual letters of recommendation would portray.

To get letters of recommendation that will significantly benefit an application requires a significant amount of work by the applicant. A letter from someone known personally to the fellowship director or staff will be very helpful in that the director knows the writer and anticipates that the letter won't "sell him bad goods." Therefore, when the letter is very laudatory, it is believed. If there is no one you know who has such a relationship, then the letter should explain why you are felt to be outstanding, with detailed examples. It is also helpful that the letter include some of your faults, with an explanation why these faults are not a major concern to the writer. This type of letter demonstrates that the writer knows the applicant well and can make an objective evaluation of the applicant, and, therefore, is believable.

Not every staff person is capable of writing such a letter. When you approach someone to write a letter of recommendation, it is fair to explain the type of letter you need, and ask if they can write such a letter. If they can't, or are unwilling to, then you can simply withdraw your request for their letter and ask someone else. The quality and source of your letters of recommendation can "make or break" your application. A candidate with a mediocre "paper trail" can be accepted into very desirable programs based on the letters of recommendation, but it takes a lot of work. You must also make sure that your letter writer gets the letters in on time. Late letters of recommendation make your application incomplete when the decisions are being made to extend interview invitations.

Interviews

The interview is designed to allow the program to see you and you to see the program. What many applicants don't seem to appreciate is that the interview processes includes every contact that is made with the program. That includes every phone call to the office of the director for applications, information, directions, etc. Because many directors implicitly trust the judgment of their secretaries, a secretary can kill an application with a simple remark like, "This person is extremely difficult on the phone. I sure hope you pick someone else!" Commonly secretaries place memos in applications about phone contacts. Don't ruin a good application by being aggressive or arrogant on the phone to a secretary.

When you come to the interview, treat everyone you talk to as an interviewer, they are! While a good exchange of information is essential, and some very important information may be obtained by talking to residents in the program, they can also kill an applicant's chances of acceptance by a comment to the director such as "We went to lunch together and this person won't fit in here." If you can, talk to the residents before the interview. You will get the simple questions answered and use your interview time to better benefit and leave a better impression because you know more about the program.

Know everything on your C.V.! It is amazing that people cannot answer questions about the research they claim to have done, or even their hobbies. If you can, attend a course given by the fellowship director prior to your interview. You will be much more knowledgeable in the area and more comfortable during the interview. If you participate in the course, it will also be easier for the fellowship director to remember you.

Significant cost savings can usually be achieved by arranging your flights so that you are staying over a Saturday night on your trip. If possible, group interviews together on one trip. It will yield significant savings in money and time. Today, many programs mandate when the interview will take place, so this may not be an option for you. Meeting the various program directors at the annual meeting of the Academy is an excellent preliminary contact; such a meeting may help you decide if a trip to the program is warranted. It is unlikely that any resident will be able financially to afford or arrange for the time away from a residency program for more than 10 interviews, even if they are efficiently arranged.

Personal Presentation

When asked a question, answer it completely, but simply. If the director waits a second to ask the next question, just wait quietly and don't feel you have to keep talking. It doesn't improve your answer and may actually harm it. Don't interrupt! Establish eye contact with whom you are talking. Giving an answer while gazing out the window does not leave a good impression. Sit in a relaxed, comfortable position in your chair. Do not place your arms and elbows on, lean across or sit on the director's desk. Try and be relaxed and confident. Be yourself!

It is obvious that you should be dressed in a professional manner. Both men and women should wear a suit and polished shoes. You won't lose points for being overdressed, but being underdressed can be disastrous. Be professional at all times, even after the interview. A well-written follow-up letter is a nice touch that leaves a good impression. Don't use a standard letter to all the programs you interview as it is easily detected and leaves a bad impression.

Information You Need

During the interview period, you need to find out all the things that won't be included in the program's literature. You will want to ask about

  • the director's travel and meeting time
  • The role the fellow plays in resident education
  • how resident and fellow responsibilities are balanced
  • Personalities of the staff
  • Is there secretarial support for your clinical and research work
  • are there funds and dedicated time available to fellows for meetings and travel and other areas of concern.


Don't lose sight that this is an opportunity to decide if you want to be involved with the program. It is not a bad idea to have a simple checklist to make sure you check all the major concerns for every program at which you interview. Prepare questions for various people before you arrive. Have at least one question to show you have thought about and have read the material sent to you about the program.

Acceptances

After all the interviews are over, hopefully you will be offered a position. Unless there is a matching program, the offers will potentially be spread out over a couple of months. What should you do if you receive an offer from a program you didn't rank as your first choice? This situation can cause more distress and anxiety in candidates than any other part of the process. Basically you have to consider your rank order, and consider if a "bird in the hand is better that two in the bush". If you really feel that the program does not offer what you want, or that you would be unhappy there, don't accept the offer. If on the other hand, your number one rank was a "flyer" to see if maybe you could get into it, or if there really were only minor differences between the offered position and your first choice, then accept the offer.

If you really want another program, then your only other choice is to call that program and tell the director that you have been offered a position and ask about your relative chances for an offer. Because this is a ploy used by some candidates who have not received an offer to attempt to force an offer from a program, many directors would simply respond by saying that their rank order has not been completed. At that point all you can do is evaluate the relative strengths of each program and the competition for a position. If the competition is high and there are not overwhelming differences and the offer is from an acceptable program, it is probably wise to accept the offer. Turning down an acceptable program and then not obtaining a position in the first choice program generally results in accepting a spot in a program you are not happy with, or delaying your fellowship, which might result in your never taking one.

Matching

To avoid some of the anxiety caused by this situation, some, not all, fellowships have gone to matching programs. They are run in much the same manner as the residency match, in which the programs turn in a rank order of candidates and the candidates turn in a rank order of the programs. A computer then matches candidates to their highest program choice that ranked them. In general, it is fair to ask a director where the program has ranked the candidate. However, the program director is not allowed to ask the candidate where the candidate has ranked the program. As a practical matter, the answer to both questions cannot be trusted by either side. An unscrupulous program director may well tell several candidates that you "ranked so high that you are assured a spot if you rank this program first." And an anxious candidate may well tell several program directors they were ranked first to attempt to obtain a desired position. If a program director requests your ranking, tell the director whatever you want, but consider other programs because that request should raise serious doubts about being involved with that program.

Contracts

Most programs will offer you a contract for your fellowship year. Most contracts will require such things as a valid state medical license and satisfactory completion of your residency. You should also check if the contract provides adequate malpractice coverage and health benefits for you and your family. Almost all fellowships have set their starting date at August lst of each year to allow the graduating resident the month of July to prepare for and take part I of the American Board of Orthopaedic Surgery certification examination and then report to the fellowship. This timing does potentially create a lapse in your health insurance coverage if it is not extended from the residency coverage or you purchase a separate interim policy. There are different methods of covering this period. Check with your residency program about continuation of coverage or explore other alterna-tives before you accept the new position.

Salaries

A fellowship should offer a salary appropriate to your level of training. Usually this would be a PGY 6 level, so the fellow should earn slightly more than the senior resident. This does not always mean more than what you earned as a senior resident, especially if you did your residency in the East and are now doing your fellowship in the Midwest or South. If a fellowship is offering a lesser salary than a senior resident, it may be an expression of how you are looked upon in that program. With the many good fellowships available, a candidate should not be expected to sacrifice a reasonable wage for "the outstanding training available in this program." If the wage is so low as to require "moonlighting" to maintain a reasonable standard of living, the educational value of the fellowship will be greatly decreased. Is the fellow required to take E.R. call to generate billing from patient care to fund the position? E.R. call for general orthopaedics isn't exactly educational for an oncology fellow. However, if you can elect to take E.R. call, to supplement your income at your discretion, that may be desirable, provided there isn't so low a base salary that you are economically forced to do it.

Health Insurance/Disability Insurance

All fellowships should provide coverage for you and your family. This is a critical factor in today's society. A "simple" schoolyard injury to a child can be extremely expensive on a fellow's salary. If you are in a car accident, what happens to your salary? If you get HIV from a patient and can't operate, are you disabled? How long will the disability payments last?

Malpractice Coverage



What type of malpractice coverage is provided the fellow? If you elect to cover the E.R., is that activity covered? Will you have to buy "tail coverage" at the end of the fellowship? Since this is an extremely costly item, if this is required, you want to take a very long and careful look at the program.

Vacation and Sick Leave

While you want an educational experience, everyone needs some time off during a year for family events, vacation, etc. Is meeting time counted as vacation? If you become ill, what happens with your salary and for how long?

Educational Benefits

Do you get meeting time and/or meeting expense reimbursement? How many meetings can you go to? Is there a book fund?

Housing Benefits

Is there subsidized housing for the fellows? Are there arrangements to help make housing affordable to a fellow in very high rent areas?

License

What type of license is required for the fellowship, permanent or temporary? If a permanent license is required, who pays for it?

Check List

The interview process can be overwhelming. You want to make sure you get all the information you need to make an intelligent and educated decision. A checklist is one way to help you get this information and categorize it. A checklist with a rating scale is an easy way to insure that you have the same information for all the programs and a method to weigh their relative strengths and weaknesses. A sample checklist is located at the end of this paper.

Summary

A fellowship can be a wonderful experience from which you will benefit for your entire orthopaedic career. Understanding your specific goals and how the process works will make this period in your career much more enjoyable and a lot less costly.

Fellowship Application Checklist:

Program:____________________________________

Address:____________________________________

Director:____________________________________

Phone:_____________________________________

Application due:______________________________

Application sent:_____________________________

Rating
CategoryLeast


Best
Comfort with Director12345
Availability of Director12345
Case Load12345
Research Requirements12345
Teaching Requirements12345
Operative Experience12345
Cognitive Experience12345
Program Balance12345
Staff Relationships12345
Resident Relationships12345
Program "Personality"12345
Program meets Goals12345
Salary12345
Health Insurance12345
Free Time12345
Living Situation12345
Family "Fit"12345

Total Score________________

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