Published 12/1/2014
Lisa K. Cannada, MD

The Fellowship Match: An Update

Remember the “good old days”? When PGY-2 residents started looking for fellowships before they had even been exposed to the range of orthopaedic specialties available? When residents interviewing for a fellowship were faced with the ultimatum “Choose now or lose it”? What was good about that?

Today’s fellowship match is an organized process for all orthopaedic specialties. More than a decade ago, the AAOS and the American Orthopaedic Association (AOA) recognized the need for an organized match for orthopaedic fellowships. The Board of Specialty Societies (BOS) Orthopaedic Fellowship Match Program Initiative (the current BOS Match Committee) worked with the orthopaedic specialty societies and residents to improve the fellowship match process.

The BOS Match Committee, which meets twice a year to address key match issues, has representatives from each specialty, along with the executive directors of the societies. It has also established relationships with the Accreditation Council for Graduate Medical Education (ACGME); the Association of Residency Coordinators in Orthopaedic Surgery; and the AOA Council of Residency Directors to learn of concerns and establish additional avenues of communication.

The match process
Today’s match process is run by three different organizations. The American Shoulder & Elbow Surgeons (ASES) has had an in-house match process for shoulder and elbow fellowships since 1992. The match takes place in December of the PGY-4 year.

The hand fellowship match is run by the National Resident Matching Program (NRMP). The match occurs in late May of the PGY-4 year and includes applicants from orthopaedic surgery, plastic surgery, and general surgery.

The remaining orthopaedic specialties (adult reconstruction, pediatrics, foot and ankle, spine, sports, tumor, and trauma) use the San Francisco Match (SF Match) with match dates in the latter half of the PGY-4 year. A major goal of the fellowship match is to have a single match day, late in the PGY-4 year. This year, for the first time, matches for both spine and foot are being held on the same day.

For the past 6 years, the BOS Match Committee has been gathering data for applicants and programs. This article summarizes some of those data.

Data summary
The number of applicants for fellowship positions continues to rise along with the number of available fellowship programs and positions (
Fig. 1). Applicants include graduates from North American allopathic and osteopathic programs as well as international medical graduates (IMGs).

The number of residents in both allopathic and osteopathic programs is increasing, which may be one reason for the increase in fellowship applicants. However, the increase in the number of fellowship programs and positions raises concerns.

Questions have been raised about too many fellows being trained in certain specialties. An abundance of fellowship-trained specialists may lead to difficulty in finding jobs and may ultimately lead to increased indications for surgery and decreased opportunities for residency programs to see certain types or numbers of cases. This issue must be taken seriously and the BOS Match Committee is encouraging each specialty to obtain information on the fellows’ ability to obtain jobs in their desired specialty.

All sports and hand programs must be ACGME-accredited due to their specialty certification. Orthopaedic trauma fellowships may be accredited by either the ACGME or the Orthopedic Trauma Association, which has its own accreditation process. Other specialty societies are working on increasing the quality of fellowship programs through the use of reading lists and recommendations on curricula and case minimums.

Recent trends
Recent trends have been quite surprising. Not all applicants turn in the rank list, and the issue of what happens to qualified, unmatched applicants does not have a good solution yet.

Up until the 2013 Match (for fellowship year beginning 2015), there were more applicants than positions in all subspecialties. In the 2013 Match, however, there was a significant number (more than 30) of unmatched domestic applicants in hand. In 2014, those numbers improved, but 10 domestic hand applicants did not match and all specialties had unmatched applicants.

In the 2014 Match, sports saw a significant decline in applicants—169 applicants matched for 226 positions. This left a large number of empty positions and programs. However, the 2015 Match has more applicants than positions in sports.

Shoulder also saw a decrease in the number of applicants in the 2014 Match (39 applicants for 42 positions), a trend that is continuing for the 2015 Match (a total of 37 applicants [22 domestic applicants] for 43 positions). Previously, shoulder and elbow had a 100 percent match rate.

The 2015 Match has the lowest number of trauma applicants (98) since 2007. Of these, 71 are domestic applicants and 81 positions are available.

Impact of ACGME rules
The ACGME rules and regulations have an effect on the match process. Key issues affecting the matches for 2014 and 2015 include the following:

  • Reduction of stand-alone fellowship programs—As of July 1, 2013, the ACGME would no longer grant new accreditation of independent specialty programs. As a result, fellowships cannot be accredited if they are not associated with a core residency program. A “stand-alone” program within an institution that does not sponsor a core residency program must take additional steps to become an ACGME-accredited sponsoring institution under the oversight of the ACGME Institutional Review Committee or change sponsorship to a geographically proximate institution that is currently ACGME-accredited.
  • Fellowship eligibility—Under current rules, graduates of osteopathic, IMG, and Canadian (Royal College of Physicians and Surgeons) programs are eligible for fellowships that will begin Aug. 1, 2015 (excluding orthopaedic surgery hand, which does not allow IMGs).

Effective with fellowship programs that begin Aug. 1, 2016, IMGs will be eligible for all ACGME-accredited fellowship programs including orthopaedic surgery hand fellowships. A new joint accreditation process between the American Osteopathic Association and the ACGME will apply to osteopathic programs. Graduates of these programs (DOs) will be eligible if their program has applied for ACGME accreditation.

  • Milestones—On Aug. 1, 2014, milestone reporting went into effect for ACGME-accredited programs that also offer fellowships. Each program must establish milestones, and the first milestone reporting is due between Nov. 3, 2014, and Jan. 9, 2015.
  • Single accreditation system—Beginning July 1, 2015, a single accreditation system will apply. The ACGME, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine have agreed to pursue a single, unified accreditation system for graduate medical education for programs in the United States. Osteopathic programs that do not achieve initial accreditation by June 30, 2020, will no longer be accredited.

Complete information on these rules is available on the ACGME website (www.acgme.org).

Additional topics
The BOS Match Committee has developed a Code of Conduct for applicants and programs to promote fair practices regarding interviews, notification of interviews, and cancellation of interviews. Applicants and programs participating in SF Match and the Shoulder Match must agree to this code of conduct.

In addition, each society has specific rules regarding post-interview communication and sanctions. The committee has also worked on providing recommendations regarding full disclosure if noncompete clauses are part of the fellowship contract, in case an applicant wants to stay in the area.

The BOS Match Committee has provided space for conducting interviews during the AAOS Annual Meeting as they realize the financial burden of multiple interviews. It is also interested in educating applicants about the process. For the past 3 years, a webinar on the “Fellowship Match Process” has been held, and a spring webinar on “Making the Most of Your Fellowship,” aimed at PGY-5s, is being planned.

The match process is not without kinks or learning curves. The BOS Match Committee will provide annual reports of the match process and continue to try to address key issues, provide data and education, and meet the needs of the programs and applicants alike.

Lisa K. Cannada, MD, chairs the BOS Match Committee. She can be reached at LCannada@slu.edu