Does it have to be “deal or no deal”?

Imagine receiving the following e-mail from a prospective fellowship program: “Congratulations, orthopaedic resident. We would like to invite you to complete our fellowship, starting in 4 years. You must, however, decide within the next 30 minutes whether to accept this offer. Otherwise, we offer this spot to another resident. We are sorry to pressure you, but the environment of the application process forces us to behave this way.”

As absurd as it sounds, this could represent the future, unless a universal match replaces the current fellowship application process. At the current rate, more than 90 percent of residents will be affected. Residents are being forced to make career choices earlier in their residencies, and are being pressured into making decisions on offers before meeting the people involved, collecting the appropriate information, and seeing various locations.

Orthopaedic education leaders are gathering data and building arguments that support the reinstitution of a universal fellowship match. We strongly support these efforts, given our own personal fellowship application experiences.

Dr. Hurbanek: 72 hours to decide
Although I obtained the fellowship of my choice, the process was very stressful. I was unable to visit programs that offered me interviews later in the year, and I missed the opportunity to meet leaders and future colleagues in my subspecialty.

During the application period, I heard the old adage “A bird in the hand is worth two in the bush” many times. It became very personal when I had to decide if the offer from Program A (the bird in my hand) was worth giving up the opportunity to interview at Programs B, C, D, and E (the birds in the bush).

I interviewed at a great program early in the process. I was excited to receive an offer shortly after the interview, but it came with a 72-hour decision deadline. My request for more time was denied. The program director stated that he would offer my spot to a wait-listed candidate and could not guarantee that it would be there if I later changed my mind. I knew it would be quickly accepted, but I had additional interviews scheduled and had already made some travel plans.

I felt like a contestant on the game show “Deal or No Deal.” Instead of looking at the bird in my hand, I heard Howie Mandel in my head asking, “What’s it going to be … deal or no deal?” I declined, but with an uneasy feeling in my stomach.

The scenario was repeated just two weeks later, during my interview with Program B. The program director there, however, allowed me more time to decide. I respected his position and appreciated that he did not pressure me. After contemplating everything, I “took the deal” and accepted the offer, relieved that the process was over.

Dr. Hanson: Exploding offers
Applying for a fellowship is how I imagine it feels to “run the gauntlet.” Many of my friends found the application process cruel, because the chaos of a matchless system pressured them to take a spot as quickly as possible. The fear of missing out on an opportunity to achieve their career aspirations drove their decision-making process.

I wanted to approach my experience differently, but felt compelled to play the game as it evolved. I found myself in the same minefield of uncertainty, wondering if I were making a career-altering mistake with each “exploding offer” that I let pass. I thought I had enough knowledge to avoid the challenges faced by my predecessors. I arrived at my final interview, however, with more questions than answers.

At that interview, I was the only applicant who did not have a “confirmed” fellowship spot. Being the only one without a safety net made me feel foolish and left me second-guessing all the opportunities I had passed up. Although I did find a fellowship position that was a great fit for me and my family, the process further solidified my belief that a formal match is critical for future orthopaedic fellows.

Suspense vs snap offers
When interviewing for a residency, the process appeared costly and time-consuming. The thought of accepting an offer on the spot seemed preferable to the routine of endless interviews, hospital tours, and airport meals. Why not eliminate the rank lists, the suspense of “Black Monday,” and the drama of Match Day?

After participating in the match-less fellowship system, however, we would gladly accept those few shortcomings so that all applicants could make important career decisions in a fair, pressure-free environment.

A fellowship match benefits both applicants and fellowship directors by leveling the playing field for all involved. It gives both the necessary time to visit, interview, and evaluate one another. Program directors do not have to schedule early interviews to attract top candidates, or select from a depleted applicant pool if they wait. Applicants can network and meet future subspecialty colleagues even if they end up at a different program.

A match would enable applicants to remain in charge of their futures, allowing them to visit various programs before making decisions. It would give them time to schedule interviews and eliminate the pressure to commit to a fellowship before thinking through the offer.

The residents we know are frustrated with the current chaos and would like to be able to eliminate fear from the process. We have persevered through 4 years of medical school, as well as grueling years of residency. Subspecialty fellowship training is the last formal step before we embark on our careers. The search for a program, although stressful, should be governed by order and a sense of fairness, integrity, and equality, rather than fear and luck.

The residency match, as well as the hand fellowship match, are proof that a match program can work. The program must be well-organized, and participants must agree to play by the rules and abide by the ethical standards that are so important to our profession. If that happens, future applicants will not find themselves in a game of “Deal or No Deal.”

Jason Hurbanek, MD, is currently a fellow in orthopaedic sports medicine at Ohio State University. He can be reached at jasonhurbanek@yahoo.com

Chad Hanson, MD, is a fellow at the University of Texas Southwestern Medical School. He can be reached at chad.hanson@alumni.utsouthwestern.edu