As many as 90 percent of orthopaedic surgery residents pursue a fellowship after residency. Reasons for doing so include but are not limited to employment/marketability, academic position/research, skill development, inadequate training, additional exposure to technology, finances, malpractice protection, personal interests, and current trends. Variation in subspecialty choice exists between genders and whether the resident desires to practice in a private or academic setting. Recently, there has been a rise in the number of residents pursuing multiple fellowships, otherwise known as “superspecializing.”

Here, we outline the current reasons residents choose to undertake fellowship(s), so that the orthopaedic field can adapt and cater to their desires.

Acquiring the data

After being granted Institutional Review Board exemption, we administered a survey to all postgraduate year (PGY) 1–5 residents in the 168 U.S. residency programs that participate in the Electronic Residency Application System. Orthopaedic surgery residents were contacted via email with a link to an optional, online, multiple-choice survey and were offered the possibility of a nominal financial award for participation.

The response rate was 48.4 percent, and respondents included 231 men and 46 women. PGY breakdown was: PGY-1 (n = 61), PGY-2 (n = 50), PGY-3 (n = 54), PGY-4 (n = 48), and PGY-5 (n = 64). In addition to obtaining demographic information, we gathered information on which fellowship(s) residents planned on pursuing; the professional setting he or she planned to work in; and the influence of each factor on their decision to choose a particular fellowship, graded on a nine-point scale.

Current trends

We found that, nationwide, residents in training have plans for fellowship that are consistent with previously reported national trends, with 94.9 percent planning to complete at least a one-year fellowship and 8.7 percent planning to complete multiple fellowships. Residents reported skill development (43.7 percent), employment/marketability (20.6 percent), and personal interest/lifestyle factors (12.7 percent) as the top three reasons for seeking fellowship subspecialty training (Fig. 1).

Fig. 2 shows the breakdown of subspecialty fellowship choices. Although 19.5 percent of respondents were undecided on a specialty, they did plan to complete a fellowship. Only 1.8 percent said they had definite plans to enter general practice directly from residency. Interestingly, more than half (52 percent) indicated they would still pursue a fellowship even if residency length were extended to six or seven years.

In our study, the top subspecialty choice among men was arthroplasty; the top choice among women was hand (Fig. 3). Both men and women had similar interest in sports medicine for a fellowship; it was the second most popular choice for men (15.9 percent) and the most popular choice for women (23.6 percent).

These metrics are in contrast to a previous study conducted by Hariri et al., which found that sports medicine was the top choice for only 11 percent of women, with pediatrics being much more popular.

Men and women also had similar criteria for choosing a fellowship, with skill development (41.6 percent and 54.3 percent, respectively) and employment/marketability (21.6 percent and 15.2 percent, respectively) being the top two reasons.

Private versus academic setting

The most significant variation in terms of chosen specialty and reasons to enter a fellowship was in practice setting. Among the residents who stated they wished to work in a private setting after graduation, arthroplasty (21.9 percent) and sports medicine (19.3 percent) were the top two choices.

In contrast, residents who planned to go into academia desired pediatrics (30 percent) and trauma (22.5 percent). Additionally, none of the residents who desired to work in a private setting chose oncology compared to 7.5 percent of academic residents (Fig. 4). Both groups cited skill development as the main factor; however, those who desired work in a private practice stated employment/marketability as the second most important factor, whereas those seeking to work in academia cited academic position/research opportunities.

Additional findings

Recently, there has been a shift toward superspecialization, whereby residents undertake more than one fellowship. In our survey, 8.7 percent of respondents planned on pursuing at least two fellowships. The most popular fellowship to include in a superspecialization was sports medicine or trauma, both of which were included in 18.8 percent of the selections
(Fig. 5). The most popular double fellowships were hand and shoulder/elbow, as well as pediatrics and sports medicine. The residents cited skill development as the major factor in determining their choices.

According to our data, it appears that residents decide whether to pursue a fellowship during or at the end of PGY-3. Only two of the 54 PGY-3 residents doubted their desire to continue their training. Similarly, the type of fellowship is determined at that time, with only three PGY-3 residents stating that they were unsure of which fellowship to pursue. All PGY-4 residents responded with a definite plan to enter practice or fellowship in a specific specialty.

We found that the two main reasons to enter a fellowship—skill development and employment/marketability—remained consistent throughout training. Personal interest as a deciding factor consistently increased throughout training, changing from 9.8 percent for PGY-1 respondents to 15.6 percent for PGY-5 respondents (Fig. 1).

Our study has limitations. As with any survey, the values were self-reported and therefore subjective. Also, there may be other factors that determine whether a person enters a fellowship that were not included in this survey. A larger sample size would have been helpful, particularly in the group reporting multiple fellowships, because only 22 residents responded to that category.

Sanar Yokhana, MD, graduated from Wayne State School of Medicine. He is completing his residency at Detroit Medical Center.

Ryan J. Kozlowski, MD, graduated from Northwestern University Feinberg School of Medicine and completed his residency at Detroit Medical Center. He is currently a fellow in hand and upper extremity surgery at Tufts University and New England Baptist Hospital in Boston.

Ali Omari, BS, is a third-year medical student at Wayne State University School of Medicine in Detroit.

Muhammad T. Padela, MD, MSc, is an orthopaedic clinical research fellow at Detroit Medical Center and cofounder of Resident Research Partnership 501(c)(3).

Zain Sayeed, MD, MHA, is a PGY-1 in the Orthopaedic Surgery Residency Program at Detroit Medical Center and cofounder of Resident Research Partnership 501(c)(3).

Sam Nasser, MD, is an adult reconstruction specialist with one year as a National Institutes of Health surgeon scientist fellow and a second year in orthopaedic research in joint replacement surgery at the University of California Los Angeles. He currently serves as the orthopaedic surgery program director for Detroit Medical Center. Dr. Nasser has more than 40 peer-reviewed publications, 10 invited reviews, and 12 book chapters. He has been in practice for more than 30 years.

References:

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2. Gaskill T, Cook C, Nunley J, et al: The financial impact of orthopaedic fellowship training. J Bone Joint Surg Am 2009;91:1814-21.
3. Hariri S, York SC, O’Connor MI, et al: Career plans of current orthopaedic residents with a focus on sex-based and generational differences. J Bone Joint Surg Am 2011;93:e16.
4. Kavolus JJ, Matson AP, Byrd WA, et al: Factors influencing orthopedic surgery residents’ choice of subspecialty fellowship. Orthopedics 2017;40:e820-4.