In 2005, approximately 90 percent of the 620 graduating orthopaedic residents matriculated into an orthopaedic subspecialty fellowship program. In January of that same year, the match process for two of the largest orthopaedic fellowship subspecialties—sports medicine and spine surgery—was dissolved by the National Resident Match Program (NRMP).

Both sports medicine and spine surgery matches collapsed due to factors that afflict most failing match programs: widespread cheating (such as offering and accepting positions outside the match), poor oversight, and ill-defined compliance regulations. Both matches fell well below the 75 percent program participation that the NRMP has set as the cutoff necessary for a match to be considered fair and effective.

Presently, the only orthopaedic subspecialty fellowships administered through the NRMP are hand surgery and foot and ankle surgery. Hand surgery has been the only stable and successful orthopaedic match over time. Foot and ankle surgery initially dissolved its match in 2001, but revived it in 2007 due to the chaos that resulted. Shoulder and elbow surgery has a stable match not administered through the NRMP. The remaining subspecialties have either dropped out of the NRMP match program or have never participated; approximately 75 percent of orthopaedic residents apply for fellowship positions through a non-matched process.

Unraveling the match
The present “decentralized” system has no uniform application, interview, or acceptance dates. In economic terms, this is known as unraveling: over time, the match process begins earlier and is more dispersed over a longer time due to the lack of a centralized system. As a result of this unraveling, residents who wish to pursue a fellowship must decide on a subspecialty earlier in their training with minimal exposure to other fields.

For instance, many applicants for spine and arthroplasty fellowships accept positions in their PGY-3 year, long before the resident is adequately exposed to the field. In some situations, the resident may not have completed a rotation in the subspecialty to which he or she is applying for fellowship. As a result, orthopaedic education and training suffer.

In addition, an unraveled market is an ideal environment for exploding offers—propositions with a specified time frame during which the applicant must accept or reject the offer. The time frames are often short, sometimes just the length of a phone call. This places tremendous pressure on the resident to make a decision, in many circumstances without adequate exposure to other programs. As a result, residents may accept the first offer for job security reasons, rather than exploring all the options and making an educated decision about fellowship programs.

Unraveling is not bad just for applicants; it creates a great deal of confusion and anxiety for program directors as well. To get the best available candidates, program directors must compete with other programs and may have to adjust and readjust their interview schedules to accommodate applicants who have been given exploding offers by other programs. Without a standardized application deadline or interview date, most programs shift the entire process forward each year.

Orthopaedics isn’t unique
The situation in orthopaedics is hardly unique. Internal medicine residents applying to gastroenterology fellowships have faced similar disarray. The gastroenterology match, like the foot and ankle surgery match, recently collapsed. Their academy leadership spent considerable time and resources to reinstitute a match process after the ensuing chaos crippled their hiring market.

The present market can also be compared to the situation faced by medical students who wanted to apply for (orthopaedic) surgery residency positions in the late 1950s. The hiring market then had completely unraveled and exploding offers were the standard. Positions were filled through early side-deals, and students often accepted less desirable options for the fear that they might not get a residency position. Programs did not abide by uniform interview dates because no enforcing body or defined penalties existed. Students and programs did not notify each other when offers were accepted, creating gridlock.

As a result of the ensuing chaos that existed throughout all of medicine, the NRMP was established. Unfortunately, the same situation as in the 1950s now applies to the orthopaedic surgery fellowship hiring market in 2007.

Many orthopaedic residents and fellowship directors believe that fellowship is a different experience than residency. In general, fellowships foster unique personal relationships and mentoring that are critical to the success of the program and the educational benefit of the participants. Although this consideration is a compelling reason to decentralize the fellowship match process, match economists have shown on multiple occasions the deleterious results that occur with decentralization of a hiring market.^1-5

The solution to the problem is simple: establish a centralized matching process. Implementing the solution is complicated and will require communication and cooperation among many orthopaedic organizations, including the AAOS, the American Orthopaedic Association (AOA), orthopaedic specialty societies, fellowship directors, the NRMP, and most importantly, residents. Each of these communities has an agenda, but if a consensus agreement can be reached, it will benefit residents and fellowship programs as well as have a stabilizing and enduring effect.

Learning the lessons of history
History shows that for any match to be successful, it must have clearly defined rules and regulations, mandatory universal participation by programs, and penalties enforced by a governing body. When the American Orthopaedic Foot and Ankle Society reinstituted its fellowship match system, it clearly outlined the criteria for program compliance, established penalties, and organized a governing body to monitor and enforce the rules. The foot and ankle match might serve as a model for the establishment of other specialty-specific orthopaedic fellowship matches or even a universal orthopaedic fellowship match program.

At the 2008 AAOS Annual Meeting in San Francisco next March, Christopher D. Harner, MD, of the University of Pittsburgh’s department of orthopaedic surgery, will lead a symposium dedicated to this topic. Hopefully, this will serve as a springboard for future reform.

The Washington Health Policy Fellows include Anil Ranawat, MD; Ryan M. Nunley, MD; James W. Genuario, MD; Alok D. Sharan, MD; Samir Mehta, MD; Aaron Covey, MD; John Flint, MD; Amir A. Jahangir, MD; and Sharat K. Kusuma, MD.

DID YOU KNOW?

• The total number of orthopaedic residency positions each year is 3,209.
• Approximately 620 orthopaedic residents graduate each year
• Almost 90 percent of graduating orthopaedic residents pursue a fellowship position.
• Three out of four (75 percent) applied for their fellowship through a decentralized non-matched hiring process.
• According to a survey of the AOA Resident Leadership Forum Class of 2005, the following are the current percentage of residents going into the different orthopaedic subspecialty fellowships (shown as percentage of respondents):
• Sports medicine: 40 percent
• Spine: 22 percent
• Hand: 8 percent
• Joints: 8 percent
• Pediatric orthopaedics: 6 percent
• Trauma: 4 percent
• Foot and ankle: 2 percent
• None indicated or fellowship deferred: 10 percent

References:

1. McKinney CN, Niederle M, Roth AE: The collapse of a medical labor clearinghouse (and why such failures are rare). American Economic Review 2005;95:878-889.
2. Niederle M, Proctor DD, Roth AE: What will be needed for the new GI fellowship match to succeed? Gastroenterology 2006;130:218-224.
3. Niederle M, Roth AE: The Gastroenterology Fellowship Match: How it failed, and why it could succeed once again. Gastroenterology 2004;127:658-666.
4. Roth AE: The origins, history, and design of the resident match. JAMA 2003;289:909-912.
5. Ranawat AS, Dirschl DR, Wallach CJ, Harner CD: Symposium: Potential strategies for improving orthopaedic education. Strategic dialogue from the AOA Resident Leadership Forum Class of 2005. J Bone Joint Surg Am 2007;89:1633-1640.