Abstract
Background:
Subspecialty training is a common part of orthopedic surgical training. The factors which influence resident subspecialty choice have important residency design and workforce implications. Our objective was to present survey data gathered from orthopedic residents regarding their fellowship plans and relative importance of factors which influence those plans.
Methods:
An anonymous online survey tool was developed and distributed to orthopedic residents through their program directors at academic institutions across the country with orthopedic surgery residency programs.
Results:
227 residents completed the survey. 97% planned to pursue fellowship training after residency. The most common presumptive subspecialties were sports (29.7%), joints (17.3%) and shoulder/ elbow (12.8%). The majority of senior residents (57%) reported that their subspecialty choice had changed during residency. When making their choice of subspecialty, residents were most influenced by their experiences working on the subspecialty service in question, their experiences working with a mentor, and intellectual interest. The factors influencing their choice were affected by gender, residency year and presumptive subspecialty.
Conclusions:
The most critical factors influencing subspecialty choice of orthopedic residents included experiences in rotations as a resident, intellectual interest and mentors in certain subspecialties. Factors influencing subspecialty choice changes over the course of residency and differ between male and female residents. This information may be useful for residency design, mentorship structuring, career counseling and for addressing subspecialty surpluses or shortages which arise in the future.
Level of Evidence: IV
Keywords: education, subspecialty, fellowship, residency, orthopaedic surgery
Introduction
Fellowship is an important and common part of modern orthopedic surgical training. In recent decades there has been a sharp increase in the proportion of orthopedic residents pursuing postgraduate subspecialty training; as it stands, over 90% of orthopedic residents plan to complete at least one year of fellowship.1-4
Because fellowship training is so prevalent in orthopedics and so influential on the future practice of orthopedic trainees, it is important to understand the factors which influence residents when choosing a subspecialty. This information has implications for residency curriculum design, mentorship structuring and career counseling. On a broader scale, understanding the factors which influence residents while making their choice of fellowship training is the first step in addressing potential shortages of surgeons in particular subspecialties.
Here we present survey data gathered from orthopedic residents regarding their fellowship plans and the relative importance of the factors which influence those plans. We analyze this data as a whole, based on year in training, and based on likely subspecialty of choice.
Methods
Survey
A survey was designed and built using SurveyMonkey software (SurveyMonkey, San Mateo, CA). The survey gathered basic demographic information including gender, year in residency, and information regarding plans for fellowship. Additionally, the survey included fourteen factors which could potentially influence choice of subspecialty (Figure 1). Respondents were asked to rate the importance of each factor in their decision-making on a five point Likert scale, with one point representing “Not at All Important” and five points representing “Very Important”.
Figure 1.
Factors included in the survey.
Distribution of Survey
The survey was distributed to 196 orthopedic residency programs directors through the American Orthopaedic Association with instructions to distribute the survey to their residents. Participation in the survey was completely voluntary, with no reward for participation offered.
Statistics
Continuous variables are reported as mean ± standard deviation. Categorical variables are reported as counts and percentage of whole. Continuous variables were compared with a student t-test. Categorical variables were compared with Pearson chi-square tests. Multiple continuous variables are compared with an analysis of variance and a post hoc Tukey Honest Significant Difference test. Alpha level was set at p<0.05. All data and statistical analyses were performed using JMP Pro (version 13.0, SAS, Cary, NC).
Results
Demographics
227 orthopedic residents representing all postgraduate years (PGY1-5) responded to the survey and were included in final analysis. 19% of respondents were female. 97% responded yes, 3% responded unsure, and <1% responded no when asked whether they planned to pursue fellowship training. 5.8% of respondents planned on pursuing multiple fellowships (Table 1).
Table 1.
Post-Residency Plans by PGY Level
| PGY1 (N= 62) | PGY2 (N = 36) | PGY3 (38) | PGY4 (55) | PGY5 (36) | ||
|---|---|---|---|---|---|---|
| Gender | Male | 80% | 81% | 84% | 82% | 81% |
| Female | 20% | 19% | 16% | 18% | 19% | |
| Are you planning on pursuing fellowship training after residency? | Yes | 90% | 97% | 97% | 100% | 100% |
| No | 2% | 0% | 0% | 0% | 0% | |
| Unsure | 8% | 3% | 3% | 0% | 0% | |
| Are you planning on completing multiple fellowships after residency? | Yes | 5% | 14% | 8% | 2% | 3% |
| No | 58% | 56% | 71% | 82% | 89% | |
| Unsure | 37% | 30% | 21% | 16% | 8% | |
| If you are currently unsure of which fellowship you will pursue, what is the likelihood that you will eventually apply for the fellowship you listed? | <25% | 3% | 9% | 2% | 0% | 0% |
| 25-50% | 35% | 26% | 6% | 0% | 0% | |
| 50-75% | 22% | 40% | 23% | 2% | 0% | |
| >75% | 27% | 20% | 46% | 9% | 3% | |
| 100% | 13% | 6% | 23% | 89% | 97% | |
| Has your fellowship of choice changed since your residency training began? | Yes | 18% | 39% | 47% | 60% | 53% |
| No | 82% | 61% | 53% | 40% | 47% |
Subspecialty Choice and Confidence Level
Overall, the most common fellowship choice was Sports (29.7%), followed by Joints (17.3%) then Shoulder/Elbow (12.8%) (Table 2). When asked how sure they were that they would eventually apply into the subspecialty they listed on the survey, the plurality of PGY1s responded “25-50% sure”, the plurality of PGY2s responded “50-75% sure”, the plurality of PGY3s responded “>75% sure” and the vast majority of PGY4s and PGY5s were fully set on their subspecialty choice. 57% of senior residents (PGY4s and PGY5s) responded that their presumptive subspecialty of choice had changed during residency (Table 1).
Table 2.
Presumptive Fellowship Choice
| N | % | |
|---|---|---|
| Sports | 67 | 29.7 |
| Joints | 39 | 17.3 |
| Shoulder/Elbow | 29 | 12.8 |
| Hand | 22 | 9.7 |
| Spine | 21 | 9.3 |
| Trauma | 21 | 9.3 |
| Pediatrics | 18 | 8 |
| Foot & Ankle | 5 | 2.2 |
| Oncology | 4 | 1.8 |
**note- one respondent did not plan on attending fellowship
Factors Influencing Choice of Subspecialty
Overall, the most important factors to respondents when choosing a subspecialty were “experiences as a resident on the subspecialty in question”, followed by “intellectual interest” then “experiences with a mentor working in that subspecialty”. The least important factors were “desire to work in an academic setting following fellowship”, “influence of family or significant other” and “experiences as a medical student on the subspecialty in question”. (Table 3)
Table 3.
Overall Importance of Factors
| **1- Not at All Important, 3- Somewhat Important, 5- Very Important | |
| Average | |
| Earning potential/salary | 3.15 |
| Lifestyle | 3.96 |
| Ease of finding a job | 3.42 |
| Desire to work in an academic setting following fellowship | 2.37 |
| Desire to work in a private practice setting following fellowship | 2.80 |
| Intellectual interest | 4.00 |
| Technical challenge/difficulty of subspecialty | 3.66 |
| Patient interactions on subspecialty service in question | 3.89 |
| Experiences as a medical student on the subspecialty service in question | 2.67 |
| Experiences as a resident on the subspecialty in question | 4.03 |
| Experience with a mentor working in that subspecialty | 3.98 |
| Extent of exposure to subspecialty in medical school/ residency | 3.55 |
| Life experience outside of medicine | 3.33 |
| Influence of family or significant other | 2.43 |
**Scoring Guide
With regard to gender, males placed significantly more importance on “earning potential/salary” (p = 0.01), while females placed significantly more importance on “desire to work in an academic setting following fellowship” (p = 0.01), “intellectual interest” (p = 0.01) and “patient interactions on subspecialty service in question” (p < 0.01).
With regard to subspecialty choice, a number of interesting differences were observed. For one, respondents interested in Spine and Joints placed significantly more importance on “earning potential/ salary” than respondents interested in Hand and Pediatrics (p < 0.01). Additionally, respondents interested in Sports, Hand, Shoulder/Elbow and Joints placed significantly more importance on “lifestyle” than respondents interested in Trauma, Pediatrics and Spine (p < 0.01). Finally, respondents interested in Sports placed significantly more importance on “life experience outside of medicine” than residents interested in other fields (p < 0.01) (Table 4).
Table 4.
Importance of Factors Based on Presumptive Subspecialty of Choice
| ANOVA (p-value) | Tukey Analysis* | |
|---|---|---|
| Earning potential/salary | <0.0001 | “Spine/Joints>Peds; Spine/Joints>Hand” |
| Lifestyle | <0.0001 | “Sports/Shouder Elbow/Hand/Joints > Trauma; Sports/Hand/Shoulder Elbow/Joints > Pediatrics; Sports/Hand/Joint/Shoulder Elbow > Spine” |
| Ease of finding a job | 0.02 | Joints > Pediatrics |
| Desire to work in an academic setting | 0.0017 | “Pediatrics > Sports/Joints; Trauma>Sports” |
| Desire to work in a private practice setting | <0.0001 | “Sports/Joints/Hand > Pediatrics; Sports > Trauma” |
| Intellectual interest | 0.41 | |
| Technical challenge/difficulty of subspecialty | 0.0023 | |
| Patient interactions on subspecialty service | 0.0006 | Hand/Joints/Pediatrics/Sports > Spine |
| Experiences as a medical student on service | 0.71 | |
| Experiences as a resident on service | 0.092 | |
| Experience with a mentor on service | 0.16 | |
| Extent of exposure to subspecialty | 0.48 | |
| Life experience outside of medicine | <0.0001 | Sports > Trauma/Spine/Shoulder Elbow/Pediatrics/Joints |
| Influence of family or significant other | 0.03 | Sports>Pediatrics |
*Post Hoc Tukey Honest Signficant Difference test performed, alpha level set at 0.05
With regard to PGY level, seniors residents placed significantly more importance on “technical challenge/ difficulty of subspecialty” (p = 0.03) and “experiences as a resident working in the subspecialty in question” (p < 0.01) than junior residents. Junior residents placed significantly more importance on “experiences as a medical student on the subspecialty in question” (p = 0.03) than senior residents (Table 5).
Table 5.
Importance of Factors Based on PGY Level
| Scoring Guide: 1- Not at All Important, 3- Somewhat Important, 5- Very Important | |||||
| Junior Resident (PGY1-3) | Senior Resident (PGY4/5) | ||||
| Average | SD | Average | SD | p-value | |
| Earning potential/salary | 3.1 | 0.9 | 3.3 | 1.1 | 0.15 |
| Lifestyle | 3.9 | 0.9 | 4.0 | 0.9 | 0.35 |
| Ease of finding a job | 3.4 | 0.9 | 3.5 | 1.1 | 0.74 |
| Desire to work in an academic setting | 2.4 | 1.2 | 2.4 | 1.2 | 0.98 |
| Desire to work in a private practice setting | 2.9 | 1.1 | 2.7 | 1.2 | 0.18 |
| Intellectual interest | 3.9 | 0.9 | 4.1 | 1.0 | 0.17 |
| Technical challenge/difficulty of subspecialty | 3.5 | 1.0 | 3.9 | 1.1 | 0.03 |
| Patient interactions on subspecialty service | 3.9 | 0.9 | 3.9 | 0.9 | 0.69 |
| Experiences as a medical student on service | 2.8 | 1.3 | 2.4 | 1.4 | 0.03 |
| Experiences as a resident on service | 3.9 | 1.1 | 4.3 | 0.8 | <0.01 |
| Experience with a mentor on service | 3.9 | 1.0 | 4.1 | 0.9 | 0.14 |
| Extent of exposure to subspecialty | 3.6 | 1.1 | 3.5 | 1.3 | 0.48 |
| Life experience outside of medicine | 3.4 | 1.3 | 3.3 | 1.4 | 0.70 |
| Influence of family or significant other | 2.5 | 1.3 | 2.3 | 1.3 | 0.22 |
Conclusion
In recent decades, the prevalence of fellowship training in orthopedics has increased substantially. A study by Emery et al. in 2012 found that over 90% of orthopedic residents pursued additional subspecialty training after residency compared to approximately 60% of residents in the 1990s.1 This finding was confirmed in additional studies by Horst et al. and Cannada et al. in 2013 and 2015, respectively.2,3 Daniels et al. found that as of 2011 there were more available fellowship positions than graduating fellows, suggesting that subspecialty choice is influenced more by resident priorities than by workforce needs.5 This has important implications for the future of the field as a whole; Salzberg et al. noted that “the problem may not be that we have a shortage of orthopedic surgeons, but rather… an oversupply of surgeons in some subspecialties and an undersupply in others.”6
Currently, the factors which influence resident subspecialty choice are poorly understood. There are numerous studies which have looked at the factors which influence medical students when choosing a residency.7-9 Other studies have analyzed the factors which influence orthopedic residents when differentiating fellowship programs within their chosen subspecialty.10-12
Fewer studies have attempted to assess the factors which influence orthopedic residents when choosing a subspecialty. Kavolus et al. noted that intellectual stimulation and variety of cases were important when choosing a subspecialty, while research potential and residency tradition were not.13 A follow up study by the same group found that senior residents tended to place greater importance on intellectual stimulation and variety of cases than junior residents, who were more concerned with geographic considerations, on call duties and financial compensation.14 Hariri et al. also found that intellectual factors were the most important deciding factor for residents choosing a subspecialty.4
Our study supports and expands on these previous studies. As in those studies, respondents to our survey listed “intellectual interest” as the most important factor overall when choosing a subspecialty. Our data also supports the critical role that resident rotations (“experiences as a resident in the subspecialty in question”) and mentorship (“experience with a mentor working in that subspecialty”) play in the decision-making process. From a residency design perspective, this suggests that program directors should aim to expose their junior residents to a wide range of subspecialties and potential mentors before they’ve made their subspecialty choice.
Furthermore, our data shows that the subspecialty decision remains malleable even in the 3rd year of residency, and that the relative importance of the factors influencing this decision changes over the course of residency. As such, program directors should continue to provide career counseling to residents regarding their subspecialty options until at least their PGY4 year, with a focus on how new experiences and changing priorities may have changed their presumptive fellowship choice.
Finally, this data provides a foundation for influencing the fellowship decisions of residents as a whole to address any surpluses or shortages of surgeons in specific subspecialties. This could be accomplished primarily by dispelling misconceptions which may exist about particular subspecialties. For example, respondents to our survey interested in Sports, Shoulder/Elbow, Hand and Joints placed significantly more importance on “lifestyle” than respondents interested in Trauma, Pediatrics or Spine. In our opinion, “lifestyle” is more dependent on practice structure and individual surgeon rather than any individual subspecialty. Ensuring that residents understand this could potentially address a source of disparities in fellowship application numbers.
Our study has a number of limitations. For one, our data was collected through a voluntary survey, creating the potential for both sampling and response bias. Additionally, analyzing any decision making process is difficult due to their inherent complexity. While we attempted to comprehensively list the factors involved in the subspecialty decision, we almost certainly missed factors which were important to some or many respondents. The factors we did include were left somewhat broad for the sake of comprehensiveness, but this possibly created room for misinterpretation of their meaning on the part of respondents. This is an important topic, which we feel warrants further study. In particular, as fellowship applications become more competitive, it would be interesting to see if residents are making, and potentially feeling locked into, their subspecialty decision at an earlier time point in their training.
References
- 1.Emery SE, Guss D, Kuremsky MA, Hamlin BR, Herndon JH, Rubash HE. Resident education versus fellowship training- conflict or synergy? AOA critical issues. J Bone Joint Surg Am. 2012;94(21):e159. doi: 10.2106/JBJS.K01331. [DOI] [PubMed] [Google Scholar]
- 2.Horst PK, Choo K, Bharucha N, Vail TP. Graduates of orthopaedic residency training are increasingly subspecialized: A review of th American Board of Orthopeadic Surgery Part II database. J Bone Joint Surg Am. 2015;97(10):869–75. doi: 10.2106/JBJS.N.00995. [DOI] [PubMed] [Google Scholar]
- 3.Cannada LK, Luhmann SJ, Hu SS, Quinn RH. The fellowship match process: The history and a report of the current experience. J Bone Joint Surg Am. 2015;97(1):e3. doi: 10.2106/JBJS.M.01251. [DOI] [PubMed] [Google Scholar]
- 4.Hariri S, York SC, O’Connor MI, Parsley BS, McCarthy JC. Career plans of current orthopaedic residents with a focus on sex-based and generational differences. J Bone Joint Surg Am. 2011;93(5):e16. doi: 10.2106/JBJS.J.00489. [DOI] [PubMed] [Google Scholar]
- 5.Daniels AH, Grabel Z, DiGiovanni CW. ACGME accredidation of orthopaedic surgery subspecialty fellowship training programs. J Bone Joint Surg Am. 2014;96(11):e94. doi: 10.2106/JBJS.M01340. [DOI] [PubMed] [Google Scholar]
- 6.Salsberg ES, Grover A, Simon MA, Krick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: Implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90(5):1143–59. doi: 10.2106/JBJS.G.01305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Johnson AL, Sharma J, Chinchilli VM, Emery SE, McCollister Evarts C, Floyd MW, Kaeding CC, Lavelle WF, Marsh JL, Pellegrini VD, Van Heest AE, Black KP. Why do medical students choose orthopaedics as a career? J Bone Joint Surg Am. 2012;94(11):e78. doi: 10.2106/JBJS.K.00826. [DOI] [PubMed] [Google Scholar]
- 8.Barbieri RL, Anastos L, Michels KB. Economic factors and the percentage of residency positions filled by United States medical graduates. Obstet Gynecol. 2005;106:581–4. doi: 10.1097/01.AOG.0000173983.88951.2e. [DOI] [PubMed] [Google Scholar]
- 9.Azizzadeh A, McCollum CH, Miller CC, Holliday KM, Shilstone HC, Lucci A. Factors influencing career choice among medical students interested in surgery. Curr Surg. 2003;60:210–3. doi: 10.1016/SD149-7944(02)00679-7. [DOI] [PubMed] [Google Scholar]
- 10.Berstein J. Factors to consider when considering a fellowship. Clin Orthop Relat Res. 2006;449:215–7. doi: 10.1097/01.blo.0000224071.08535.b7. [DOI] [PubMed] [Google Scholar]
- 11.Niesen MC, Wong J, Ebramzadeh E, Sangiogio S, SooHoo NF, Luck JV, Eckardt J. Orthopedic surgery fellowships: The effects of interviewing and how residents establish a rank list. Orthopedics. 2015;38(3):175–8. doi: 10.3928/01477447-20150305-05. [DOI] [PubMed] [Google Scholar]
- 12.Krupto TA, Cannada LK. How to approach fellowship match: Tips for the applicant and fellowship programs. J Orthop Trauma. 2018;32(1):e36–e38. doi: 10.1097/BOT.0000000000001049. [DOI] [PubMed] [Google Scholar]
- 13.Kavolus JJ, Matson AP, Byrd WA, Brigman BE. Factors influencing orthopedic surgery residents’ choice of subspecialty fellowship. Orthopedics. 2017;40(5):e820–4. doi: 10.3928/01477447-20170619-01. [DOI] [PubMed] [Google Scholar]
- 14.Matson AP, Kavolus JJ, Byrd WA, Leversedge FJ, Brigman BE. Influence of trainee experience on choice of orthopaedic subspecialty fellowship. J Am Acad Orthop Surg. 2018;26(3):e62–7. doi: 10.5435/JAAOS-D-16-00701. [DOI] [PubMed] [Google Scholar]