Career Perspectives for Pediatric Orthopaedic Trainees and Early Practitioners: A Panel Discussion

Abstract

The life of a pediatric orthopaedic surgeon involves many more challenges than just those seen in our clinics and operating rooms. These begin during fellowship, when key decisions occur regarding training and the development of mentor and peer relationships. Then, selection of a surgeon's first job opportunity and ensuing practice development involve significant potential career turning points. Our panel of young surgeons offers thoughts and advice on these situations, hoping that current and future trainees will benefit from the knowledge gained through their experience in entering and beginning a successful career in pediatric orthopaedics.

Key Concepts

• (1)When selecting a fellowship, it is valuable to understand one's learning style and to consider family needs.
• (2)After discovering what positions may be available, match each potential position's professional and personal opportunities with your needs.
• (3)Your initial practice will evolve to your ideal professional endpoint over years of effort and development.
• (4)The optimal work-life relationship is possible with good communication with your partner/family and with a good team of supporting healthcare staff around you.
• (5)Regular attendance at the POSNA annual meeting and involvement in committee work can be a resource and provide tremendous professional satisfaction.

Introduction

Pediatric orthopaedic surgery is a field that requires long-term education and training before entry and then evolves over the course of a career, which can include significant work and life stresses and challenges [[1], [2], [3]]. When an orthopaedic surgeon has a complex question, seeking answers from colleagues, mentors, and/or available literature is common. However, the variability of each individual's practice makes it difficult for colleagues/mentors to guarantee definitive advice. Studies that aim to identify factors associated with orthopaedic surgeon turnover are limited by low survey response rates, ambiguously defined variables, heterogeneously subspecialized participants, and the fact that the actual turnover rate is unknown [[4], [5], [6]]. Therefore, one of the best things mentors can do is share experiences. The Resident Communication Committee (RCC) of the Pediatric Orthopaedic Society of North America (POSNA) assembled a panel of current pediatric orthopaedic surgeons to provide guidance. All panelists completed a pediatric orthopaedic fellowship, some recently and others years ago. We hope the insights provided help current and future trainees determine how to approach the journey.

Panel members

Will Cutchen, MD: Will completed a fellowship at Children's National Hospital in Washington, DC, in 2023 and is now at the University of South Alabama.

Lee Haruno, MD: Lee completed a fellowship at Children's Hospital of Philadelphia in 2024 and is now at Hawaii Pacific Health.

Dustin Greenhill, MD: Dustin completed a fellowship at Texas Scottish Rite Hospital for Children in 2018. He initially joined St. Christopher's Hospital for Children in Philadelphia before moving to St. Luke's University Health Network, where he is associate program director of their orthopaedic surgery residency.

Karen Bovid, MD: Karen completed a fellowship at Children's Orthopaedics of Atlanta at Scottish Rite in 2013. She then began practice in Kalamazoo, MI, at Western Michigan University Homer Stryker MD School of Medicine.

Brandon Ramo, MD: Brandon completed a fellowship at Texas Scottish Rite Hospital for Children in 2011. After fellowship, he began his career in Orlando before returning to Scottish Rite Hospital in Dallas.

Panel discussion

Finding the right fellowship can be a daunting task. Tell us how you approaches the fellowship match process–what was helpful, and what would you change?

Will: The first thing I did was review the POSNA fellowship database with my wife. We went through the list together, and I applied to places where we thought we would be happy. I knew I wanted to go somewhere that would provide a robust operative experience and prepare me for life after fellowship. I did not have a job lined up during interview season, so I wanted to find a program with exposure to everything. During interviews, I asked the current fellows about their experience and how well-prepared they felt for life after fellowship. When I made my rank list, I ranked programs based on how well they would prepare me for life after fellowship, and if they were located somewhere that my family would be happy.

Lee: Fortunately, there are many excellent programs, each with opportunities to work with incredible mentors and patients, so the match often comes down to where you think you fit most. It is essential to assess the overall culture of a program and how they prioritize/incorporate fellow education into the group or institution. When evaluating programs, I selected criteria that were important to me: robust clinical/operative experience, culture emphasizing mentorship/collegiality, and the opportunity to train with co-fellows if possible. To learn more about programs beyond an interview, speaking to mentors and current/recent fellows is essential. Fellows love to talk about their programs, especially if it's a great experience. Similar to Will, I interviewed virtually due to COVID-19, but building camaraderie with your interview group (and future colleagues!) is a lot of fun and something I wished our cohort had more of an opportunity to do.

Once in fellowship, fellows can understand the program with more clarity. What factors did you experience during fellowship that were most influential to your experience?

Will: I was fortunate to have a job before starting the fellowship. My first 6 months were assigned rotations with all the attendings, during which I saw a wide range of pathology and cases. Since I knew I would have a relatively general pediatric orthopaedic practice with no sports/spine, I used the second half of the fellowship to see the cases and pathology I needed to prepare for that practice. I chose to be in the trauma room regularly since trauma was going to be significant in my practice, especially starting. I also spent clinic time with each attending. It was valuable to see their clinical flow and how they approached patients and families when discussing treatment options. Finally, I was fortunate that all my attendings in the fellowship were very invested in my success. I still text them about patients and cases to get their thoughts.

Lee: Factors to consider when picking a fellowship include curriculum style, number of co-fellows, mentorship opportunities, exposure to specific clinical/research infrastructure, or patient populations, and, of course, location/personal factors. Most programs fall on a spectrum of “structured rotation/mentorship model” or “choose your own adventure.” Programs with structured curriculums ensure well-rounded exposure, enabling fellows to develop an excellent foundation. These programs often have elective time, allowing opportunities to delve deeper into a subspecialty interest. Programs featuring a flexible model allow greater fellow autonomy in tailoring the experience but require discipline and planning to develop that well-versed/broad foundation. Understanding your learning style, training background, and career goals will determine which style resonates with you. I also was very excited to train with co-fellows. Sharing the fun and learning of fellowship with a close-knit group was one of the best parts of the experience, not to mention building career and life-long friendships. Fellowship mentors will be a significant career influence, and the relationships you foster continue to grow in the collegial and engaging pediatric orthopaedics community.

POSNA has grown tremendously over the years. It was initially formed in 1984 and now has more than 1500 members [7]. As a member now, how was POSNA a part of the fellowship and early career experience for you?

Will: As previously stated, I used the POSNA database to identify the fellowships I applied to. I joined POSNA during my fellowship year. I attended the annual meeting in Nashville, which was a fantastic experience. I learned a lot. I also met many fantastic people I probably would not have met otherwise. At the end of the fellowship year, I decided to be involved in POSNA committees. I am now part of both the RCC and POSNA Wellness committees.

Lee: Attending the International Pediatric Orthopaedic Symposium (IPOS®) as a 4th-year resident is an excellent opportunity to meet faculty from different programs and your fellow applicants as well. Scholarships are available for residents to attend, and experiences such as Guided Growth (a mentoring program pairing residents with faculty) and the Top Gun competition are participant favorites. Candidate POSNA membership is available once you match into a fellowship, which is an opportunity to consider participation in POSNA committees. The Resident Engagement Subcommittee (RES) is open for residents. I am now part of the RCC and the Justice, Equity, Diversity, and Inclusion Committee.

What factors did you consider when pursuing that first job?

Dustin:Availability–You can't work where there is no job! The online POSNA Job Board is helpful, but there are other resources (American Academy of Orthopaedic Surgeons website). Sometimes, surgeons are offered an unlisted job. Davis et al. estimated that >50% of orthopaedic trauma fellows may find a job via word-of-mouth. The authors noted that one-third of applicants felt they “settled,” so begin your job search early to optimize availability and make informed decisions [4].

Opportunities (Professional and Personal)–A job should provide opportunities to build your desired practice. Ideally, there are also good mentors nearby. In addition to residency and fellowship mentors, I am forever in debt to Dr. Marty Herman for helping me mature as an attending. I was invited to immediately incorporate scoliosis into my practice with continued mentorship from an expert. The institution is a level 1 pediatric trauma center in an academic setting, holds weekly case conferences, teaches 6 residency programs, and has a top-down, team-based approach. That was an excellent (rare) opportunity. Familiarity with a program helps minimize inevitable unknowns. If you are not familiar with the practice, do your research.

My wife is happiest, close to her family. With the reasonable exception of fellowship training, that has always been a priority. To some people, “close” is a 30-min drive, and to others, it's being 30-min from an airport.

Capabilities–Be realistic about your abilities and an institution's capabilities. For complex clinical goals, consider the entire setting. For example, scheduling and performing scoliosis surgery consistently takes more than a new surgeon [[8], [9], [10]]. Ideally, the institution can provide you with the appropriate patient population, referrals, equipment, an experienced team (nurses, therapists, nonorthopaedic physicians, etc.), and more.

How did you approach part II of the ABOS certification?

Dustin: I've worked alongside past and present ABOS board members. These surgeons are genuinely great people dedicated to upholding standards within our profession and ensuring ongoing opportunities for self-assessment and professional development. Board certification is designed to do both [11]. These leaders have informed me to study throughout residency, fellowship, and as a new attending, as if you're preparing to defend each patient's entire clinical course to the ABOS. Practice in an ethical/evidence-based manner. Welcome advice from colleagues and mentors. Do not ignore or overlook complications. Then, once you are board-certified … keep practicing this way!

Logistic preparation starts with the ABOS Part II Examination website [11]. The earliest decision you'll make is when to start your first job. Currently, you need to be credentialed by your institution after fellowship by November 1st to take the ABOS Part II examination 2 calendar years later. The ABOS prefers you remain in that same practice until taking the exam. Osteopathic board certification (AOBOS) has slightly different requirements that, if applicable, you should know when you graduate from residency.

Changing employers is not something most of us plan on doing but is something that happens to many young orthopaedic surgeons [5]. What factors are essential in leading someone to stay or change jobs?

Dustin: Organizations use objective strategies to optimize multifactorial decisions. For example, military operations are formally planned using the Military Decision-Making Process. Businesses conduct analyses of Strengths, Weaknesses, Opportunities, and Threats (SWOT) during strategic planning. However, “career transitions are like onions. They're complex, and there is usually much more to them than we see on the surface.” [12].

My humble advice: “Optimize your most important variables such that your chosen professional and personal life make the most sense.” Some of the variables necessary to my spouse and I were to be in proximity to her family, shorter commute time, rich professional opportunities, presence, and stability within our children's lives (ie, school district), cost of living, and compensation elements.

When a surgeon leaves a job, it does not imply an initial wrong choice. During my first job, my wife and I spent years unable to find a new house as the COVID-19 pandemic began and real estate prices soared. Our older daughter was about to start first grade at her fifth school. Access to real estate, a stable school district, and my wife's parents seemed more manageable when I was approached with a new job opportunity. In this new job, however, I needed to help formalize pediatric orthopaedic care within a 15-hospital network, be the first pediatric-trained scoliosis surgeon at that institution, and take call at an Adult Level 1 Trauma Center. Although I had comprehensive training, I do not think I would have readily accepted and/or excelled in this role without outstanding mentorship during my first job, experience from my first institution, and having completed board certification.

Survey studies cite location, financial decisions, and interpersonal issues as notable factors associated with accepting or leaving a job [4,5,13]. Board-eligible surgeons rarely leave their first job within 2 years [6]. Moreover, unpublished ABOS recertification data suggests roughly 35% of board-certified orthopaedic surgeons change jobs within approximately 10 years [14].

How have you incorporated POSNA participation into your first few years in practice?

Dustin: Most importantly–attend the annual meeting! I love our field so much that prioritizing this meeting seems easy. As time passes, these POSNA members who live in different parts of the country feel like close friends. I understand that now. Getting involved in committee work is academically and professionally rewarding. Research contributions to POSNA can come from your institution, but POSNA has also allowed me to join multicenter research projects. Lastly, involving residents in research contributions to POSNA or IPOS® increases their desire to participate.

Determining what we want our career to be and then developing it can be challenging. How did you decide what your practice would look like and then build it?

Karen: I am the only fellowship-trained pediatric orthopaedic surgeon in my region, so I need a general pediatric orthopaedic practice to serve the population's needs. For me, this is great because one of the things that drew me to pediatric orthopaedics was the incredible variety of problems that we treat in many different anatomic areas with various types of procedures. Early on, I did everything I was trained to do in fellowship. However, I realized that in general practice, some issues come up infrequently and perhaps would be better cared for by someone who does that procedure regularly. For example, I was 5 years into practice and saw a patient who would benefit from a vertebral column resection. I realized I hadn't done that procedure in 3 years and that patients would likely be better served by referring them to a colleague specializing in complex spine issues. Over time, I've transitioned to referring patients with complex problems to specialized centers while building a robust general pediatric orthopaedic practice. I built strong relationships with the pediatricians in the region by being available and responsive to their questions and consults. This helped develop my practice and resulted in many referrals. I made templates for notes on common diagnoses that included educational information about the condition for both the patient and the referring physician. I frequently give Grand Rounds for Pediatric and Family Medicine groups on topics they request. I traveled to practices and Emergency Departments around the region when I first started practice to meet the teams there and provide my contact information. Patients and families who appreciate the care you've given them will refer others. Over time, the practice has grown to the point where I'm recruiting a partner to help care for all these kids.

Brandon: I will start by answering half-jokingly that my practice evolved me. I decided to pursue a pediatric fellowship partly because I had difficulty determining which aspect of orthopaedics, I enjoyed the most. Other than arthroplasty (which didn't appeal to me personally), I enjoyed most aspects of orthopaedics. I chose pediatrics for the opportunity, in some ways, to remain a generalist and get to operate, in theory, on all body parts (like tumor surgery but without as much bleeding!). As 12 years in practice in a large academic group have gone by, I have colleagues who have gradually narrowed their practices, and by default, mine has narrowed. I intentionally let go of arthroscopy and several other things, like the adolescent hip. As time went by, diagnoses like Developmental Dysplasia of the Hip (DDH) and clubfoot started to disappear as I had partners who wanted to specialize there. As my group has become more subspecialized and my partners have assumed the care of many subspecialty patients, so have I become more subspecialized, for better or worse. I think the degree of subspecialization, in pediatrics but perhaps in any orthopaedic group, will directly correlate to how large your group is and the population size surrounding you geographically.

I am happy with where my career has led me. My elective practice is now primarily spinal deformity/scoliosis with an even crazier niche of early onset scoliosis (EOS). While this is not where I envisioned myself perhaps 10 years ago, spending most of your time in one arena certainly has a lot of advantages, like improved efficiency in the OR, comfort with complex cases (as much as one can be when some kids have “no answers”), and also allows a focus on research and teaching if you are inclined to those. One lesson I learned early is if you agree to do something for your group (EOS, complex foot deformity, frames, etc.), you can bet it will eventually grow and consume a more significant percentage of your time as years go by. Concerning building a practice, I think “just say yes” remains the best attitude; early on, you may need help from a mentor.

What is your perspective on whether a second fellowship is helpful to someone considering subspecialization?

Karen: I initially thought I might do a second fellowship in sports, but since I wanted to focus on peds sports, I didn't need the adult-focused experience of many sports fellowships (shoulder arthroplasty, rotator cuff repair, etc). I ultimately chose a pediatric orthopaedic fellowship with a robust sports experience, which prepared me well to care for kids with sports-related pathology in the pediatric population. If you plan to join a large academic pediatric orthopaedic group with many subspecialists, a second fellowship could be helpful. Some pediatric fellowship programs have more flexibility and may allow you to tailor your experience to meet your practice goals.

Brandon: Concerning the trend of doing a second fellowship, I did not consider this. For family and financial reasons, I guess I needed to “just get a job.” If you carefully select a fellowship and good mentors, you can be well versed in most complex things (perhaps not all, but undoubtedly several) after 5+1 years of training. I think actively seeking mentors both at your home institutions or externally, being willing to travel to visit experts, and attending specialty courses like the Limb Lengthening and Reconstruction Society (LLRS) or various spine meetings is a way to expand your knowledge without committing an entire year. Or if you can get support from your institution for “mini” fellowships lasting 6–12 weeks, I think these can be pretty useful. Just remember that some of the things you will be doing in 20 years may not exist today (there were no magnetically controlled spring distractions or ratcheted growing rods when I was a fellow), so no matter what you do, you will be learning the job until you retire.

How have you navigated achieving an appropriate relationship between work and home, and what advice might you offer?

Karen: This is an ongoing challenge for me, especially as my kids get involved in more and more activities. Planning to request time off for the first day of school and school breaks, planning fun experiences and vacations together and reserving date nights with my husband have been important. I'm fortunate to have a fantastic team with a skilled physician assistant, ortho technician, radiology technician, and medical assistant who can help manage patient issues while in the OR and when I'm away. Early in my practice, I said yes to every opportunity, which taught me a lot and led to more opportunities. I'm now in a stage of my career where I am learning to be selective about which things I dedicate my time toward and which opportunities I refer to someone else.

Brandon: Be honest with your spouse about how much time you commit to work. Be honest with your partners about when you can and can't work (take personal time!). Be honest about which aspects of the balancing act make you truly happy, and focus your energy there. But it's 100% true that you can't be happy at one without the other. Some things will happen at work that you have to put over your family, like managing complications. But there are times when your family needs to come first, too. Some simple ideas: Avoid scheduling your most significant cases before vacation, and rely on your partners for help. When you go on vacation, leave town so you can't drive to work.

How has your career been affected by POSNA involvement (committees, education, research, and society leadership)?

Karen: Being involved in POSNA has allowed me to meet fantastic people and colleagues. I've enjoyed participating in the work of different committees and having the opportunity to lead one. I appreciate how approachable and generous many of our field experts are in sharing their knowledge, expertise, and support. It is also really fun to spend time with other people who love caring for kids with orthopaedic problems, educating others to do the same, and advancing our field with new knowledge on how to do it better. POSNA is my professional home, and I am so grateful to be a part of this organization.

Brandon: POSNA has been a great home base for me. Connections and reunions at the annual meetings remain significant to my professional satisfaction. Serving on committees can be rewarding and a good way to meet great people. I'm humbled and incredibly grateful that I've had the opportunity to go on the traveling fellowship and be selected for the POSNA Leadership Program recently. These have sincerely been some of the most remarkable opportunities to learn and grow in my career thus far, both for the relationships made and the perspectives gained. I think perhaps the most noteworthy thing about POSNA is the senior members, who, by and large, are just terrific, wise human beings who often love nothing more than to help by sharing their experiences, good and bad, with treating kids. One piece of advice for young surgeons in POSNA is not to be afraid to seek out a wizened, senior POSNA member at the meeting to show a case, ask for career or technical advice, or whatever. I will bet almost uniformly they will be willing to help, teach, share, and even mentor if asked. It's a unique, focused, altruistic group of bright and talented individuals.

Author contributions

Jeffrey B. Peck: Conceptualization, Project administration, Supervision, Writing – review & editing, Writing – original draft. William Cutchen: Writing – review & editing, Writing – original draft. Lee Haruno: Writing – review & editing, Writing – original draft. Dustin Greenhill: Writing – review & editing, Writing – original draft. Karen Bovid: Writing – review & editing, Writing – original draft. Brandon Ramo: Writing – review & editing, Writing – original draft.

Funding

There was no funding provided for the article.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.