Recently, James H. Beaty, MD, of the Campbell Clinic, conducted a roundtable discussion on the value of pursuing a specialty fellowship and on how the fellowship process has changed over the years. Joining Dr. Beaty were Timothy L. Beck, MD, who recently completed a fellowship and is now practicing in Tyler, Texas; Timothy M. Bert, MD, a fifth-year resident at Campbell Clinic; Lisa Cannada, MD, chair of the BOS Match Oversight Committee and assistant program director at Saint Louis University; and program directors Christopher D. Harner, MD, University of Pittsburgh; William N. Levine, MD, Columbia University, New York City; and Peter J. Stern, MD, University of Cincinnati.
Dr. Beaty: When did your interest in a fellowship begin to develop? During medical school? As a resident?
Dr. Bert: For me, the interest developed during residency, from exposure to the sports medicine staff at the Campbell Clinic. And, of course, my father, Jack M. Bert, MD, mentored me.
Dr. Beck: My interest developed in my third year of residency, after my rotation with E. Greer Richardson, MD.
Dr. Cannada: I was a medical student at the University of Maryland when I saw the Shock Trauma Center for the first time. Andrew R. Burgess, MD, showed me the excitement of being in trauma. I worked my entire residency with the goal of getting back there for my fellowship.
Dr. Levine: As a PGY-2, I got involved in research with John Richmond, MD, and knew then that I would pursue fellowships in sports and shoulder/elbow.
Dr. Harner: My interest evolved during residency. I was interested in spine because we had several good faculty in that area, including Edward N. Hanley Jr, MD. I had good mentors, but in my third or fourth year, I decided to pursue sports.
Dr. Stern: In my second year of residency, I was on the hand service and I remember spending the night doing several digital replants with a plastic surgeon who later became chief of plastic surgery at Mass General. For reasons totally unclear to me now, I said, “That’s what I want to do.”
Dr. Beaty: What did you use as resources when you were looking for a fellowship? What guided you to find and select a certain one?
Dr. Stern: At the time, only four or five fellowship programs of the caliber that I wanted were available. I interviewed at two, and got into my first choice.
Dr. Harner: Sports fellowships were relatively new when I was looking. Freddie Fu, MD, had a significant influence in bringing me back to Pittsburgh.
Now, I think the senior residents have a major role in steering junior residents to fellowship programs.
Dr. Levine: Pipelines are common. Certain programs will send a resident to a specific fellowship almost every year. The program is comfortable; they know the “product” they are getting. If the program is happy and the residents are happy, they’ll bring positive feedback back to their younger peers.
Dr. Beck: Dr. Richardson, who was the fellowship director at the Campbell Clinic, was instrumental in helping me decide. With no match, it was essentially a phone call, like a gentleman’s agreement.
Dr. Beaty: Dr. Bert, you’re currently in the fellowship process. What resources have you been using?
Dr. Bert: I think the best resources were the impressions from my sports medicine faculty and the fifth-year residents who had recently been through the match process. I also obtained information from the San Francisco Match website.
Dr. Beaty: What do you think about interviewing for a job, signing a contract, or committing to a position before or during a fellowship?
Dr. Cannada: I think that committing yourself early does not let you see what is available. You have to experience two or three interviews before you can really determine what you want in a practice. And what you want in a practice will change during your fellowship because you are looking at the training differently than you did as a resident.
Dr. Levine: If you get a job before your fellowship, you are relying on your residency mentors—who can obviously be great people. But a fellowship provides both mentors and specialty training. Those mentors might lead you to a much better job than the one offered during residency.
Dr. Beaty: Geography plays a role when medical students are seeking positions as orthopaedic residents. Does it have the same impact in fellowship selection?
Dr. Stern: I don’t think it plays quite as big a role. It’s only one year, not a big commitment. Family circumstances and need tend to be other considerations.
Dr. Harner: We’ve looked carefully at the Top 10 reasons in our sports medicine match surveys, and geographic location is pretty far down the list.
Dr. Levine: Some people think it’s an adventure, especially since it’s only one year. Clearly, some residents will come to New York City for one year even though they would not have come for a 5-year residency.
Dr. Beaty: The increase in the number of orthopaedic residents seeking a fellowship between 1970 and 2010 has been dramatic. As AAOS president in 2007, I knew what a monumental task it would be to establish a coordinated match program. What helped us succeed this time?
Dr. Levine: One of my fourth-year residents got a phone call from a fellowship director asking if he were coming to the interview, because of 16 people who were scheduled to interview, 15 had already accepted spots. Residents were going to one interview, being offered a fellowship spot, and given 24 hours to decide.
As a residency director and a fellowship director, I thought this was crazy. How can we demand residents to be professional and use professionalism as a core competency with that type of unprofessional behavior? To me, that was complete hypocrisy.
Having coordinated matches has dramatically changed the playing field in favor of residents, but it’s also helped fellowship programs.
Dr. Stern: Seeing the success of the hand match helped serve as a catalyst for building the fellowship match through the San Francisco Match Program, which most musculoskeletal fellowships use today. The devil was in the details, but the hand match was a model for success and fairness for both the applicant and the program.
Dr. Harner: My frustrations with the sports medicine fellowship match drove me to try to unify the process. We had 220 applicants a year going into sports and it was simply chaos.
Dr. Cannada: The Orthopaedic Trauma Association annual meeting was a “free-for-all.” Deals were being made in the bathroom or in side rooms, shaking hands, and it really became the focus of the meeting. We wanted a fair process so that applicants could evaluate more programs and find the right one. A match process would put larger, more well-known programs on equal footing with smaller programs.
The match program enabled all programs to reach applicants and eliminated the chaos at the annual meeting. People could make educated choices about the fellowship that fit their personalities and training needs.
Dr. Beaty: Dr. Beck, what’s the difference between today’s match process and what you went through?
Dr. Beck: There were a lot of “gentlemen’s agreements” when I was looking for a fellowship. A phone call was made and that was the deal. I think today, residents have more exposure to more programs and places they might not have looked at otherwise. It’s definitely a positive change.
Dr. Beaty: Is the fellowship match program working?
Dr. Harner: This is the third year and it has done very well. Plus, we now have data to review—where people are doing fellowships, how many match their number one choice. We have information that can help the residents apply. For example, the data indicate that residents don’t need to apply to more than seven or eight programs, because that will result in a match 99 percent of the time. So they just have to interview with eight to ten programs, not 20 programs.
The match in sports medicine has also created a significant increase in our fellowship directors’ involvement. We now have 100 percent attendance at all our fellowship directors meetings.
Dr. Levine: Seven years ago, the New York shoulder and elbow programs started coordinating interview dates so that residents didn’t have to fly several times to New York. We’ve now expanded that coordination through the American Shoulder and Elbow Society central office. Interview dates are posted early so residents know when and where the interviews are. This helps avoid conflicts and overlap.
The residents appreciate the respect that we show them and each other. It’s evolved into a really outstanding process.
Dr. Cannada: This is the third year of a formal match in trauma. We started with a computer application process, followed by an informal match with a set date, and then the formal match through San Francisco Match website. It’s enabled us to turn our attention to both sustainability and quality.
In general, all the specialties are working well as a group, which means better opportunities for everyone. We don’t want to see the process implode. As long as we are using the data to improve the process for both the fellowship programs and residents, we can continue to have a sustainable match and meet the needs of every specialty.
Dr. Beaty: The Pediatric Orthopaedic Society of North America didn’t have a functioning match process. Peter M. Waters, MD, was one of the leaders who convinced the fellowship directors that it was in the best interest of the residents to move forward with the fellowship match. A few years into it, I think things are going well.
Dr. Bert, what are the residents you know saying about the match?
Dr. Bert: A few of the older residents who went through the process prior to the fellowship match had negative experiences. I believe residents think the fellowship match has been a positive change.
Dr. Beaty: What are the potential risks and worries about the future of the fellowship match?
Dr. Harner: One of the most concerning issues is the number of fellowship positions that go unmatched. If this number reaches 40 percent to 50 percent, then the match is at risk to unravel. For example, sports medicine had 213 fellowship positions, but only 187 matches this year. Will we always have about 25 unfilled positions? Does that mean sports medicine has too many positions? It’s that “mismatch” that can threaten the match.
Dr. Levine: Many orthopaedic educators are concerned that the work hour issues may lead residents to seek two fellowships. Orthopaedic practices are adding nonphysician practitioners and fellowships because they don’t have the residency support they used to have.
I’m also concerned about what the increasing numbers of people applying for second fellowships will mean in the future. Obviously, some of it is job-driven. For example, every year we interview people who have done a hand fellowship and are now applying for a shoulder/elbow or sports fellowship.
Dr. Beaty: Let me mention another issue. If some programs go a year or two without a match, they may begin to fear for the loss of their fellowship and may be tempted to go outside the match. The opposite situation is too many applicants for too few spots, which means that some residents don’t match in that specialty.
Dr. Cannada: That is a concern. Currently, most specialties have more applicants than positions. As a result, residents apply to multiple fellowships in one year because they are afraid of not matching. The number of residents participating in the National Resident Matching Program has increased to more than 660 in 2011, from 615 in 2006. That means more residents entering fellowships.
We also have to consider the osteopathic orthopaedic residents, whose numbers have increased by 35 percent in the past three years, as well as the international medical school graduates. If the number of programs stays the same, we have to develop suggestions and solutions for dealing with the increased number of applicants so that we can maintain the integrity of the match.
Dr. Stern: Another issue for hand and sports is the emergence of specialty certification, which requires training through an Accreditation Council for Graduate Medical Education (ACGME)-accredited program. This has caused a number of non-accredited fellowships to diminish by attrition.
Dr. Harner: True, but one could argue that specialty certification has improved the quality of the fellowships overall. We’re proud that 95 percent of all sports programs have ACGME accreditation; it has significantly improved the education of our fellowships.
Funding for programs is also a potential problem. Programs that lose funding may not survive.
Dr. Levine: Within the fellowship match committee, we’ve been dealing with the ethics of disclosure when interviewing candidates for a fellowship. Shouldn’t the residents know where the source of funding for that fellowship is generated?
What happens if the fellowship is industry-supported and that industry support disappears after the resident matches, but before the fellowship begins? We have been trying to develop rules of conduct for all of the fellowship matches. It’s controversial, but I think it’s important.
Dr. Cannada: Some fellowships are getting funded for 2 years, so that residents interviewing now will know that the program will have funding when they’re ready to begin.
Dr. Beaty: Are any other problems out there on the horizon?
Dr. Harner: I think one is the concern about costs for the residents to go to the interviews. We are trying to decrease the costs for the residents by telling them the number of programs they should be interviewing.
Dr. Levine: Another issue is work hours. Resident directors are very anxious about all of their PGY-4s being gone at that critical time—January through March. Some programs only give residents 2 or 3 days for interviews, which limits the number of programs residents can visit.
Dr. Cannada: One of our earlier goals was a universal match date. But due to the number of applicants, the number of residents who’d be traveling, work hour regulations, and staffing issues, a universal fellowship match date wouldn’t work. So instead, we are concentrating on other points to make the match a continued success. We are open to suggestions and comments.
Dr. Harner: For residents, the fellowship match has become part of the culture of orthopaedics. Most are appreciative of the opportunity to look and decide with their spouses and significant others what they want to do.
The Fellowship Match Program
Approximately 90 percent of all graduating orthopaedic residents plan to enter a postgraduate fellowship program. Until recently, however, no coordinated orthopaedic specialty match program existed. Following a 2007 symposium at the American Orthopaedic Association (AOA) annual meeting, and a joint meeting that included leaders from the AAOS, the AOA, and the American Board of Orthopaedic Surgery, a strategic plan for instituting a fellowship match across orthopaedics was developed and implemented.
The establishment of the Orthopaedic Fellowship Match Program Initiative in 2008 and the subsequent formation of the AAOS/Board of Specialty Societies (BOS) Match Oversight Committee began to bring order to chaos and changed the way orthopaedic surgeons selected (or were selected for) a fellowship program. The current AAOS/BOS Match Oversight Committee follows and monitors specialty fellowship matches. Committee members meet annually to review the data, discuss concerns, and make recommendations to improve the process for residents and fellowship programs.