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AAOS Now

Published 4/1/2019
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John P. Lubicky, MD, FAAOS, FAAP, FAOA

The Financial, Educational, and Service Impact of Applying and Interviewing for Orthopaedic Fellowships

Less than 10 percent of graduating orthopaedic surgery residents go directly into general orthopaedic practice. More than 90 percent further their education and gain subspecialty training beyond their five years of residency. Of course, within each of the subspecialties, there are “plum” fellowships that distinguish themselves because of the “big names” on their faculties. Others are desirable for different reasons. Regardless, there is competition among the candidates to obtain the best fellowships, and the programs also want the best participants.

When I was a resident, the fellowship application process was fairly simple. Fellowships advertised their positions in journals or were found by word of mouth; they were frequently truly apprenticeships, with one main mentor; they were somewhat informal by today’s standards; and they were not adjudicated by a matching program. Additionally, in 1978, when I applied for fellowships in spine surgery and pediatric orthopaedic surgery, there were only a few fellowships and a small number of candidates. A position was offered and accepted by verbal promises on both sides, and the deal was sealed with a handshake. Sometimes this process failed. Sometimes a program would revoke an offer after it was accepted because a better candidate was identified; conversely, at times, a candidate reneged after finding a better program. But those numbers were small and manageable—hard feelings notwithstanding.

Eventually, a more formal process was developed to increase fairness and commitment by both programs and candidates. The process, which eventually became manageable for large numbers of candidates, required applications and face-to-face interviews with faculties.

Because of competition for positions, candidates often feel compelled to apply to a large number of programs. Several studies have delineated the fellowship application process—a PubMed search seeking articles that include both the terms “fellowship” and “orthopaedic surgery” yielded 960 articles—and annual updates are sent to each specialty society, program directors, and residents. The data suggest that, in most specialties, there are more applicants than positions and that residents go on an average of 10 or more interviews and spend thousands of dollars.

This, in turn, creates a new set of problems, including financial hardships due to costs of travel and lodging. The travel also adversely affects residents’ educational time by taking them away from what may be their only rotation on a given orthopaedic subspecialty service. Consequently, services are impacted by a missing team member. Together, the effects are not inconsequential. Clearly, a process that reduces costs and educational impacts would help both resident applicants and their home programs.

To study this issue in more depth, three of my department colleagues, Daniel Grant, MD; Barry McDonough, MD; and Phillip Bostian, MD, devised a survey to identify the costs and associated drivers of the interview process. The survey was sent to post-graduate year four (PGY-4) residents throughout the country after the conclusion of the match period.

A cover letter explaining the study was emailed to residency coordinators who were members of the Association of Residency Coordinators in Orthopaedic Surgery and residency directors who were members of Orthopaedic Residency Directors. They then offered the survey to residents (n = 681). The letter provided a website address for the anonymous survey. The survey was released at the end of the match period and was offered only to PGY-4 residents to limit recall bias. Answers were reported electronically and anonymously to study personnel.

The online survey consisted of eight free answer questions:

  1. List the state of your current residency program.
  2. To which fellowship subspecialty did you apply?
  3. Estimate your total expenses while applying to fellowships.
  4. To how many programs did you apply?
  5. How many interviews did you attend?
  6. What number on your rank list was the program to which you matched?
  7. To how many interviews did you need to fly?
  8. How many days of work did you miss while interviewing?

Responses were tabulated from April 17, 2015, to June 10, 2015, with 94 percent of participants responding in the month of April. The total possible number of respondents was 613, the total number of respondents was 83, and the calculated response rate was 13.5 percent. Respondents were from 31 states, and all regions of the United States were represented. Twenty-one participants were from the Midwest, 21 from the Northeast, 29 from the South, and 10 from the West. Of the respondents, 8.43 percent (n = 7) were seeking a foot and ankle fellowship, 20.48 percent (n = 17) a hand fellowship, 6.02 percent (n = 5) a pediatrics fellowship, 8.43 percent (n = 7) an adult reconstruction fellowship, 3.61 percent (n = 3) a shoulder and elbow fellowship, 15.66 percent (n = 13) a spine fellowship, 32.53 percent (n = 27) a sports medicine fellowship, 3.61 percent (n = 3) a trauma fellowship, and 1.20 percent (n = 1) a tumor fellowship.

The mean total cost for the application process was $5,094 (range, $800–10,000). Residents applying to spine fellowships incurred the most costs, at a mean of $6,038, and residents applying to pediatric fellowships had the lowest costs, at a mean of $3,407.

Residents from the Midwest had the lowest costs, at $4,390, whereas residents from the South had the most expenditures, at $5,350. No significant differences were noted in total costs across subspecialties or regions. On average, residents applied to 23 programs, attended 11 interviews, and took eight flights to attend interviews. There were no significant differences in the number of flights, programs applied to, or interviews attended based on fellowship subspecialty. Applicants interviewed at 48 percent of the programs to which they applied. Each resident averaged 11.4 days of missed work, amounting to approximately one day per interview. Average cost per interview was $454. Among respondents, 44 percent matched at their first choice, 95 percent matched by their sixth-ranked choice, and 99 percent matched at or above their seventh-ranked choice.

When respondents were separated into quartiles based on total cost, the lowest quartile averaged $2,447 (range, $800–3,499), the middle quartiles averaged $4,719 (range, $3,500–6,999), and the highest quartile averaged $8,319 (range, $7,000–10,000) (P < 0.0001). When the researchers examined the lowest, middle, and highest quartiles, determining significance by comparing to the middle quartiles, they noted the following: programs applied: 16.6 (P = 0.001), 24.4, and 28.0 (P = 0.207); interviews attended: 8.8 (P = 0.002), 11.5, and 13.0 (P = 0.140); rank matched: 2.6 (P = 1.000), 2.6, and 2.4 (P = 0.934); flights to interviews: 5.1 (P = 0.001), 8.1, and 10.2 (P = 0.024); days of work missed: 7.8 (P = 0.008), 11.6, and 14.5 (P = 0.057); and cost per interview: $297 (P < 0.0001), $444, and $664 (P = 0.002).

A limitation of the study is its low response rate, which may have been the result of loss of interest by the residents in the process because it was done at that point. Nevertheless, the data show that, on average, an applicant will miss more than two weeks of work to interview, with 95 percent of applicants interviewing at an average of five or more programs in excess of what is required to match. The typical applicant spends $2,270 or more and misses at least a week of training, interviewing at more places than are needed to reach a 95 percent match rate.

This demonstrates the need for fellowship programs, subspecialty groups, and applicants to devise ways to reduce costs.

Melcher, Ashlagi, and Wapnir proposed an interview match that would precede the existing match. Their plan would kick in after applications are submitted. Thereafter, candidates and programs would submit rank lists that could be used to fill limited interview spots. The authors cited articles by Bernstein and Ashlagi et al., who proposed ways candidates and programs could indicate interest in each other. Melcher et al., wrote: “By ranking candidates and programs highly, both essentially are respectively signaling their strong preference for each other. Therefore, fewer interviews might be sufficient for candidates and programs to identify mutually desirable matches and reduce the number and costs of interviews. If the program and candidate interview slots remain unfilled, a secondary match could be performed to fill unmatched interview slots.” The authors further delineated the process in their article.

Some specialties attempt regional interview days/weekends to minimize travel. The Orthopaedic Trauma Association holds informational sessions that allow candidates to get a feel for programs and determine those for which they wish to apply and possibly interview. AAOS offers rooms for interviews at the Annual Meeting through the Board of Specialties Match Committee. Many applicants believe it is important to get a “feel” of a place and be able to talk to current fellows to intelligently rank each program.

The fellowship application process is important to program faculties and residents alike, yet it is also important to acknowledge that the process is disruptive and costly. Serious discussions among fellowship and residency directors are needed to attempt to improve the process so that matching mutually interested parties is less of a burden. Candidates also should be counseled on applying to programs that are reasonable for their goals, objectives, and qualifications.

John P. Lubicky, MD, FAAOS, FAAP, FAOA, is with the Department of Orthopaedics at West Virginia University School of Medicine in Morgantown, W.Va.

References:

  1. Grant DR, Bostian PA, McDonough EB: Cost of applying to orthopaedic fellowship: an analysis of associated variables. Case Orthopaedic Journal 2016;13:119-22.
  2. Melcher ML, Ashlagi I, Wapnir I: Matching for fellowship interviews. JAMA 2018;320:1639-40.
  3. Bernstein J: Not the last word: want to match in orthopaedic surgery residency? Send a rose to the program director. Clin Orthop Relat Res 2017;475:2845-9.
  4. Ashlagi I, Braverman M, Kanoria Y, et al: Communication requirements and informative signaling in matching markets. New York, NY; ACM Press 2017:263.