Pearls: Getting the Most Out of Your Fellowship Year

In an era of increasing subspecialization, fellowship has become the capstone to our orthopaedic education and provides much of the skillset that surgeons rely on in their practice [2]. Job-listing sites increasingly advertise for physicians with fellowship training [3], and residents have heard the message loud and clear: More than 90% of orthopaedic residents performed at least one fellowship in 2013 [2], with some residency graduates even performing two [1]. Maximizing productivity and efficiency during fellowship is challenging, but doing so can jumpstart a career.

The trick is to get the most out of this important year of education.

To do that, you must first determine whether you would like to practice in the private or academic sector, or a hybrid of the two. If you have academic aspirations, try to identify research mentors and take on as much research as you can handle while identifying projects that you will be able to complete during fellowship. When you are a fellow for a year, there is little opportunity to build your own data sets. Most productive fellows perform research on data that is already collected or available in the medical record because of the time crunch. It’s important to understand where data are available so that you can be as productive as possible in a short period of time. I wrote a recent “Pearls” column here in Clinical Orthopaedics and Related Research® to help fellows decide which research projects are most likely to bear fruit [5]. If you are interested in academics, try to engage—even during fellowship—in committee work, reviewing for journals, and networking with other academics. In addition, you might wish to devote special attention to more-complex procedures—such as revision surgery or osteotomies (in arthroplasty fellowships), and cartilage-repair procedures (in sports fellowships)—during that year of advanced training, so as to better prepare for the kinds of referral practices you might develop in a first academic job after graduation.

By contrast, if you are interested in community or private practice, try to focus on gaining efficiency in the common procedures that might compose the kind of practice you aspire to develop. Spending time on research during fellowship may be less important than benefiting from more repetitions in the operating room, particularly for high-volume procedures like primary arthroplasties (and newer techniques for performing them, like the direct-anterior approach), ACL reconstructions, and rotator cuff repairs. Team building, practice-promotion techniques, and specific skills in marketable procedures (for example, endoscopic carpal tunnel release, less-invasive spine surgery) are other priorities you’ll need in private practice perhaps even more so than in academics. Once you have a job lined up (or when you’ve narrowed the list of contenders down), you may wish to speak with them to solicit their guidance about the procedures and skills you might be able to master that would complement the current skillsets of the practice group.

Hybrid practices, or “privademics” [4], could be suitable for those interested in pursuing academic endeavors in a private practice structure that emphasizes understanding the financial and marketing aspect of building a successful practice or “brand.” These types of practices, like the Rothman Institute in Philadelphia, PA, USA, for example, may offer you the opportunity to participate in clinical research while also honing your skills in the operating room and developing a private-type clinical practice. When researching hybrid practices, you should consider whether you want to take on the pressure of academic publishing while also learning how to cultivate and maintain the financial and management aspects of a surgical practice [4].

A few final suggestions might apply equally whether your goals after graduation include private practice, academic orthopaedics, or a combination of both:

• Don’t underestimate the importance of clinic. A mentor of mine once told me, “During fellowship, you will want to maximize the amount of time spent in the operating room. However, during your first 6 months of practice, you will wish you did more clinic.”

• Give as much attention to learning when not to operate as you do to learning how to operate. Keep a notebook, and record specific indications, especially for uncommon procedures. See if you can identify (and keep notes on) factors associated with patients or conditions that you can associate with poorer results. Learn from the mistakes of mentors; it’s much easier than learning from your own.

• Develop your “voice.” Take notes that describe how each attending explains each diagnosis to his or her patients. See what works, and what doesn’t.

• Make lists in the operating room. Equipment, setup, step-by-step descriptions of approaches, and in particular, the differences among attendings who do the same procedure. These will be especially handy in the first months on your own as you develop your way to do it.

• How do your attendings deal with complications and poor outcomes? Some are better at this than others. Identify traits that make them better or worse at this and emulate the ones that do this well.

• Identify the attendings in your fellowship that provide you with the best mentorship, answer your questions the best, and have a genuine interest in helping with your career. They will be invaluable to you when you are faced with difficult decisions early in your practice. They form a team of experts that you can send difficult cases to and help you decide what to do in these complex situations.