Abstract
Background
Mentorship and research have been shown to be important decision factors influencing medical students to pursue a particular specialty. The cost of applying to orthopedic surgery residency is at an all-time high. The purpose of this study is to identify the factors which increase the likelihood of medical students matching into orthopedic surgery, identify the timing and strength of impact these factors have on medical students’ career choices, determine how many students have chosen orthopedic surgery prior to beginning medical school, and compare the financial impact of applying to orthopedics.
Methods
608 medical students were surveyed 5 times during medical school (at the start of M1, M2, M3, M4 year and after the match process) to identify ongoing factors that influence their career choice and ultimately matching in orthopedic surgery. Unadjusted odds ratios and cost analysis were used to determine the factors influencing specialty choice. Level of evidence: III
Results
Students who matched into orthopedic surgery were more likely to be mentored by an orthopedic surgeon at all 5 survey points (M1 OR=30.93, M2 OR=12.38, M3 OR=17.96, M4 OR=65.2, Match OR=215.45) and involved in orthopedic surgery research at the last 4 survey points (M2 OR=20.05, M3 OR=14.00, M4 OR=12.00, Match OR=1566.60) compared to students who did not match into orthopedic surgery. 10 out of 19 students (52.6%) who matched into orthopedic surgery listed the specialty as their preference in the M1 survey. Students who matched into orthopedic surgery spent $8,838.80 on applications and interviews, while students applied to and matched into other specialties spent an average of $6,173.4 (p-value=0.007).
Conclusion
Many students have a predetermined plan to enter orthopedic surgery prior to medical school. Mentorship and research are important factors increasing students’ interest in orthopedic surgery and ultimately leading to a successful match process. Going through the orthopedic surgery match process is significantly more expensive than other specialties.
Level of Evidence: IV
Keywords: residency, education, financial
Introduction
Orthopedic surgery is one of the more competitive specialties1 therefore, it’s important to identify the factors which may influence a student’s decision to pursue orthopedic surgery and then successfully match into their desired specialty. Many studies have looked to identify the factors influencing specialty choice, however most are single, cross-sectional studies with limited conclusions.10,12,26,29 There are a few studies looking at specialty groups, such as primary care26 and surgery,7,27 and these studies all identified that mentorship within their specialty had a positive correlation in pursuing their specialty. Berger et al. found research to be a key factor for entering into surgical specialties.7 This study is a continuation of that previous work and includes a few of the same participants. However, that paper analyzed all surgical specialties and only included one medical school class which was still in their third year. In an orthopedic surgery specific study, Johnson et al. found many students know they want to specialize in orthopedic surgery before entering medical school and role models were influential for specialty choice. They also suggested there may be differences between men and women, and the timeframe they become interested in orthopedic surgery.18
Applying for residency through the ERAS process is very expensive; the average student who matched into orthopedic surgery in 2015 spent a total of $5414.54 on applications and travel expenses,9 mainly due to an increase in applications. In 2006, the average number of programs matched orthopedic applicants applied to was 48.4, rising to 83.1 by 2017.19 Applicants who see themselves as weaker applicants are applying to significantly more programs and doing more away rotations,19 thus increasing expenses for the applicant and the number of applications each program receives. Therefore, it benefits both program directors and applicants to be aware of the factors influencing students to pursue a career in orthopedic surgery. The significant costs for students applying to numerous orthopedic surgery programs has been well described, however, it has not been compared to students applying to other specialties. During the 2020-2021 residency interview season the AAMC recommended all interviews to be held virtually.5 Since then, many proposed changes for future cycles have been proposed including, interview24 and application caps,15 offering virtual and in person interviews. Therefore, a robust cost analysis of the traditional in person model is imperative for future decision making on how to best conduct residency interviews as many recent papers cite decreased expenditures as a reason to continue virtual interviews but none include a thorough analysis of the decreased cost5,11,30,31 and only one included data comparing the cost of in-person and virtual interviews for a small cohort of applicants during the COVID-19 pandemic.6
Rationale
The first reasons for conducting this study is the fact that there are limited studies on the influential factors for a medical student’s decision to pursue orthopedic surgery and ultimately matching into an orthopedic surgery residency, all of which are single cross-sectional observational studies.8,18,28 These studies begin to identify common themes yet leave a lot of room for further investigation on the key factors and when they are important. Secondly, it is necessary to identify when students are becoming interested in orthopedic surgery thus allowing potential interventions to increase interest to be effective. Finally, with the recent change to virtual residency interviews due to COVID-19 it is necessary to have a robust evaluation of the financial impact that the traditional in person model had on applicants allowing future decision to be made. The first aim of this study is to evaluate students who have successfully matched into orthopedic surgery to identify the factors that influenced them to choose orthopedic surgery, as well as the identify the timing and strength of impact for these factors compared to their peers who did not match into orthopedic surgery. The second aim of this study is to demonstrate the financial impact of matching into orthopedic surgery compared to other specialties.
Methods
Using a retrospective cohort method as follow up to preliminary findings from by Berger et al.,7 this study was granted exception status by our Institutional Review Board. There was no source of funding for this study. All medical students (608) who matriculated at our institution between 2013 and 2016 and thus graduated between 2017-2020 were eligible to participate (152 per class). 5 surveys were distributed to each study participant. The M1 survey was administered during orientation week at the start of medical school. Subsequent surveys (M2, M3, M4) were administered to students at the beginning of each school year. The final survey was administered at graduation. The surveys were based on year in medical school (M1 = first year, M2 = second year, M3 = third year, M4 = fourth year, post-match = graduation). Data collection began in 2013 and includes the matriculating classes of 2013, 2014, 2015, and 2016. The questions on the survey were derived from information collected during discussions with medical students and residents, regarding the factors they felt influenced specialty preference, as well as a literature review of similar surveys.10,17,18,26,27 The surveys included a list of specialty choices, along with questions regarding demographics, finances, debt levels, academic history, extracurricular activities, history of physician shadowing, previous or current mentorship, and a personal and lifestyle preferences Likert scale. Each survey was compared to the student’s previous responses, allowing for a longitudinal analysis.
Descriptive statistics, such as age, marital status, family, and debt status, for the study population, were calculated. Participants were then stratified into students who matched into orthopedic surgery (Group A-Table 2), students who stated they planned to enter orthopedic surgery at any point during medical school but matched into another specialty (Group B-Table 3), and students who matched into a specialty other than orthopedic surgery (Group C-Table 3). Group C includes all students in group B, as well as all students who never stated they wanted to pursue orthopedic surgery. Odds ratios were calculated to determine the likelihood of a student matching into orthopedic surgery or another specialty (Group A compared to Group C). Odds ratios were also calculated for students who matched into orthopedic surgery, compared to students who indicated plans to pursue orthopedic surgery, but then matched into another specialty (Group A compared with Group B). The number of programs applied to, number of interviews received, and interviews attended were compared between the students who matched into orthopedic surgery and the students who matched into other specialties. These were compared using two-tailed t tests (Group A compared to Group C). These results were then used to calculate the estimated cost of applications, interviews, and total expenses. All calculations were done using SPSS software version 23.0 (IBM-SPAA, New York, USA).
Results
608 students were eligible to participate from 4 separate graduating classes. The number of responses and response rates for the M1, M2, M3, M4, and match surveys were 536 (88.2%), 482 (79.3%), 425 (70.0%), 348 (57.2%), 433 (71.2%) respectively (Appendix Table A). During this time frame 580 students went through the NRMP match process,20-23 thus adjusting the match response rate to 74.7%. There were 28 students who matched into orthopedic surgery from the eligible study participants.20-23 Of these 28, 19 completed all five surveys (64%) as demonstrated in Table 1 and 2, 2 did not complete the M1 survey but completed the subsequent surveys (Table 2), and one student only completed the match survey, bringing the total to 22 completed match surveys (response rate=79%) as demonstrated in Match Column of Table 2.
Table 1.
Demographic Information For All Study Participants That Completed M1 Surveys Separated by Case Control Groups at Matriculation
| Study Demographics | All Students (%) | Orthopedics Matches (%) | Students interested in orthopedics but match another specialty | All Student who matched into a specialty other that orthopedics |
|---|---|---|---|---|
| Age at matriculation | 23.6 | 23.7 | 22.55 | 23.57 |
| Male | 299 (55.9) | 15 (78.9) | 36 (72.0) | 284 (54.9) |
| White | 373 (75.4) | 16 (88.9) | 37 (77.1) | 357 (69.1) |
| Married | 78 (14.6) | 2 (10.5) | 8 (15.7) | 76 (14.7) |
| No Children | 517 (96.4) | 10 (89.5) | 49 (96.0) | 500 (96.7) |
| Family in Medicine | 113 (21.1) | 5 (26.3) | 12 (23.5) | 108 (20.9) |
| Family in Orthopedics | 38 (7.1) | 2 (10.5) | 2 (22.96) | 5 (0.97) |
| Total in Cohort | 536 | 19 | 51 | 517 |
Table 2.
Survey Responses For Experimental Variables For Students That Matched Into Orthopedic Surgery
| Orthopedic Matches Demographics (Group A) | M1 (%) | M2 (%) | M3 (%) | M4 (%) | Match (%) |
|---|---|---|---|---|---|
| Mentor | 2 (12.5) | 10 (62.5) | 10 (66.7) | 7 (77.8) | 18 (85.7) |
| Mentor in Orthopedics | 2 (12.5) | 5 (31.3) | 5 (33.3) | 6 (66.7) | 18 (85.7) |
| Research | 6 (31.6) | 14 (87.5) | 12 (80.0) | 5 (62.5) | 14 (93.3) |
| Research in Orthopedics | 2 (10.5) | 8 (50.0) | 7 (46.7) | 3 (37.5) | 13 (86.7) |
| Yes, debt from undergrad | 6 (31.6) | ||||
| Yes, debt from med school | 14 (73.7) | 10 (62.5) | 10 (66.7) | 8 (72.7) | 12 (85.7) |
| Yes, debt impact on choice | 7 (38.9) | 7 (43.8) | 6 (40.0) | 3 (33.3) | 9 (69.2) |
| Selected orthopedics for that survey | 10 (52.6) | 11 (68.8) | 8 (53.3) | 8 (88.9) | 22 (100.0) |
| Total Responses | 19 | 16 | 15 | 11 | 22 |
Factors Influencing Choosing and Matching into Orthopedics
Significant factors associated with students more likely to match into orthopedic surgery, as compared to their classmates who did not match into orthopedic surgery, were male gender (OR=3.06, 95% CI=1.01-9.36), family in orthopedic surgery, (OR=12.05, 95% CI=2.18-66.58), performing research in any specialty during M2 and M3 year (M2 OR=5.18, 95% CI 1.6-23.07, M3 OR=4.16, 95% CI=1.16-14.96), performing orthopedic surgery research during M2, M3, M4 and Match surveys (M2 OR=20.05, 95% CI=6.88-58.41, M3 OR=14.00, 95% CI=4.68-41.85, M4 OR=12.00, 95% CI= 2.51-57.45, Match OR=1566.60, 95% CI=133.23-18419.00), and having an orthopedic surgery mentor was significant during M1, M2, M3, M4, and Match surveys (M1 OR=30.93, 95% CI=4.06-235.72, M2 OR=12.38, 95% CI=3.87-39.60, M3 OR=17.96, 95% CI=5.25-61.39, M4 OR=65.2, 95% CI=14.23-298.73, Match OR=215.45 95% CI=55.23-840.48) (Table 5). Notable variables that were not significantly different between the students who matched into orthopedic surgery and those who matched into another specialty were; marital status, children, debt from undergrad or medical school, or if debt influenced specialty choice (Table 5). All survey results are available in attached appendix. Students who were interested in orthopedics, but matched into a specialty other than orthopedic surgery, were more likely to have performed non-orthopedic surgery research before medical school (OR=0.25, 95% CI=0.08-0.78) (Table 3). During the M4 and match surveys, the group that matched into orthopedic surgery were more likely to have an orthopedic mentor (M4 OR=6.50, 95% CI=1.32-32.08, Match OR=2370.0, 95% CI=234.78-23,924) (Table 3). The group that matched into orthopedic surgery was more likely to be doing orthopedic research at the time of the match survey (Match OR=227.5, 95% CI=18.99-2726.1) and also stated that debt affected specialty choice (Match OR=5.46, 95% CI=1.26-23.78) (Table 6).
Table 5.
Unadjusted Odds Ratios Comparing the Students That Matched Into Orthopedic Surgery Compared to the Students Who Matched Into Another Specialty
| Orthopedics matches vs. non-orthopedics matches | M1 | M2 | M3 | M4 | Match | |
|---|---|---|---|---|---|---|
| OR | OR | OR | OR | OR | ||
| (95% CI) | (95% CI) | (95% CI) | (95% CI) | (95% CI) | ||
| Male | 3.06 (1.013.06 -9.36) | |||||
| White | 2.68 (0.612.68 -3.52) | |||||
| Family in medicine | 1.35 (0.481.35 -3.84) | |||||
| Family in Orthopedics | 12.0 (2.2012.0 -66.58) | |||||
| Married | 0.68 (0.15-3.01) | 0.69 (0.24-2.02) | 1.28 (0.40-4.11) | 2.73 (0.67-11.17) | 0.61 (0.20-1.87) | |
| Children | 3.46 (0.74-16.19) | 1.87 (0.41-8.70) | 2.37 (0.51-11.08) | 3.64 (0.72-18.51) | 0.79 (0.17-3.69) | |
| Mentor | 0.69 (0.15-3.10) | 2.22 (0.79-6.21) | 2.46 (0.83-7.33) | 2.55 (0.52-12.45) | 2.94 (0.83-10.30) | |
| Mentor in Orthopedics | 30.93 (4.06-235.72) | 12.38 (3.87-39.60) | 17.95 (5.25-61.39) | 65.2 (14.23-298.73) | 215.45 (55.23-840.48) | |
| Research | 0.29 (0.11-0.89) | 5.18 (1.16-23.07) | 4.16 (1.16-14.96) | 2.60 (0.61-11.18) | 6.04 (0.78-46.84) | |
| Research in Orthopedics | 2.41 (0.53-11.07) | 20.05 (6.89-58.41) | 14.00 (4.68-41.85) | 12.00 (2.51-57.45) | 1566.5 (133.23-18418.61) | |
| Debt from undergrad | 0.73 (0.280.73 -1.97) | |||||
| Debt from medical school | 0.51 (0.18-1.46) | 0.33 (0.12-0.95) | 0.38 (0.13-1.15) | 0.47 (0.12-1.83) | 1.80 (0.39-8.22) | |
| Debt affects specialty choice | 1.12 (0.43-2.95) | 1.25 (0.46-3.41) | 1.03 (0.36-2.97) | 0.69 (0.18-2.65) | 2.85 (0.85-9.51) |
Bolded values denotes statistical significance of p <0.05
Table 3.
Survey Responses for Experimental Variables for Students That Were Stated They Were Pursuing Orthopedic Surgery at Some Point During Medical School But Matched Into Another Specialty
| Non-orthopedic Matches that were interested in orthopedic in medical school Demographics (Group B) | M1 (%) | M2 (%) | M3 (%) | M4 (%) | Match (%) |
|---|---|---|---|---|---|
| Mentor | 4 (8.89) | 24 (53.3) | 21 (56.8) | 23 (67.6) | 25 |
| Mentor in Orthopedics | 0 (0.00) | 10 (22.2) | 11 (29.7) | 8 (23.5) | 0 (0.00) |
| Research | 33 (64.7) | 28 (62.2) | 28 (75.7) | 11 (64.7) | 18 |
| Research in Orthopedics | 12 (23.5) | 13 (28.9) | 15 (40.5) | 5 (28.4) | 1 |
| Yes, debt from undergrad | 14 (27.5) | ||||
| Yes, debt from med school | 43 (84.3) | 35 (77.8) | 27 (73.0) | 22 (68.7) | 21 (87.5) |
| Yes, debt impact on choice | 20 (40.0) | 20 (44.4) | 13 (39.4) | 9 (30.0) | 7 (41.2) |
| Selected orthopedics for that survey | 29 (56.9) | 27 (60.0) | 18 (48.6) | 9 (25.0) | 0 (0.00) |
| Total Responses | 51 | 45 | 37 | 36 | 37 |
Table 6.
Unadjusted Odds Ratios Comparing the Students That Matched Into Orthopedic Surgery Compared to the Students Who Did Not Match Into Orthopedic Surgery But Stated at Some Point During Medical School That They Were Pursuing Orthopedic Surgery
| Orthopedics matches vs. non-orthopedics matches that were interested in Orthope-dics in medical school | M1 | M2 | M3 | M4 | Match |
|---|---|---|---|---|---|
| OR | OR | OR | OR | OR | |
| (95% CI) | (95% CI) | (95% CI) | (95% CI) | (95% CI) | |
| Male | 1.45 (0.411.45 -5.16) | ||||
| White | 2.37 (0.472.37 -11.98) | ||||
| Family in medicine | 1.16 (0.351.16 -3.89) | ||||
| Family in Orthopedics | 5.88 (0.505.88 -69.04) | ||||
| Married | 0.63 (0.12-3.29) | 0.36 (0.11-1.22) | 0.67 (0.18-2.54) | 2.45 (0.52-11.60) | 1.00 (0.25-4.08) |
| Children | 2.88 (0.37-22.08) | 1.71 (0.28-10.50) | 1.26 (0.21-7.79) | 3.33 (0.47-23.78) | 1.38 (0.17-11.15) |
| Mentor | 1.47 (0.24-8.89) | 1.46 (0.45-4.70) | 1.52 (0.43-5.35) | 1.67 (0.29-9.42) | 2.64 (0.64-36.00) |
| Mentor in Orthopedics | 6.43 (0.54-76.33) | 1.59 (0.45-5.66) | 1.18 (0.32-4.27) | 6.50 (1.32-32.08) | 227.50 (18.98-2726.11) |
| Research | 0.25 (0.08-0.76) | 4.25 (0.86-21.04) | 1.28 (0.38-4.30) | 0.91 (0.16-5.20) | 6.22 (0.69-55.77) |
| Research in Orthopedics | 0.38 (0.08-1.90) | 2.46 (0.76-7.96) | 1.28 (0.38-4.30) | 1.44 (0.30-9.42) | 227.5 (18.99-2726.11) |
| Debt from undergrad | 1.22 (0.391.22 -3.84) | ||||
| Debt from medical school | 0.52 (0.15-1.85) | 0.48 (0.14-1.63) | 0.74 (0.20-2.71) | 1.21 (0.26-5.56) | 0.86 (0.13-5.88) |
| Debt affects specialty choice | 0.95 (0.32-2.88) | 0.97 (0.31-3.07) | 1.03 (0.29-3.57) | 0.88 (0.19-4.09) | 5.46 (1.26-23.77) |
Bolded values denotes statistical significance of p <0.05
Table 4.
Survey Responses For Experimental Variables For All Students That Matched Into a Specialty That Was Not Orthopedic Surgery
| All non-orthopedic matches demographics (Group C) | M1 (%) | M2 (%) | M3 (%) | M4 (%) | Match (%) |
|---|---|---|---|---|---|
| Mentor | 72 (17.2) | 199 (42.9) | 182 (44.8) | 195 (57.9) | 257 (70.0) |
| Mentor in Orthopedics | 2 (0.46) | 17 (3.54) | 11 (2.7) | 10 (3.0) | 0 (0.00) |
| Research | 314 (60.7) | 266 (57.5) | 200 (49.0) | 82 (39.0) | 169 (69.8) |
| Research in Orthopedics | 24 (4.60) | 22 (4.75) | 24 (5.9) | 10 (4.8) | 1 (0.41) |
| Yes, debt from undergrad | 199 (38.5) | ||||
| Yes, debt from med school | 437 (84.5) | 398 (83.3) | 341 (84.0) | 284 (85.0) | 227 (76.9) |
| Yes, debt impact on choice | 184 (35.6) | 183 (38.4) | 154 (38.2) | 112 (34.1) | 105 (44.1) |
| Selected orthopedics for that survey | 29 (5.6) | 27 (5.83) | 18 (4.4) | 9 (2.7) | 0 (0.00) |
| Total Responses | 517 | 482 | 411 | 339 | 411 |
Developing an Interest in Orthopedics
10 out of 19 students (52.6%) who matched into orthopedic surgery and completed both the M1 survey and the Match survey, listed the specialty as their preference in the M1 survey. 8 out of those 10 students (80%) never indicated an interest in another specialty on any survey completed. The other two students initially indicated in interest in orthopedic surgery, then switched to another specialty, but then ultimately matched into orthopedic surgery. 9 out of the 19 (47.3%) switched from pursuing another specialty into orthopedic surgery. There were two additional students who only completed the match survey without completing any prior surveys.
The cohort of 9 students who developed an interest in orthopedic surgery during medical school and matched into an orthopedic surgery were associated with having mentors in orthopedics in the M1, M3, M4, and match surveys (Mentor in orthopedics M1 OR=61.86, 95% CI=7.60-503.85, M3 OR=14.36, 95% CI=2.51-82.32, M4 OR=163.00, 95% CI=17.40-1527.1, Match OR=125.68 95% CI=23.38-675.59) as well as doing research within orthopedics during M2, M3, and Match surveys (Research in orthopedics M2 OR=10.02, 95% CI=1.74-57.71, M3 OR=12.00, 95% CI=2.54-56.69, Match OR=1446, 95% CI=80.54-25961) (Table 7).
Table 7.
Unadjusted Odds Ratios Comparing the Students That Matched Into Orthopedic Surgery But Initially Reported an Interest in Another Specialty Compared to the Students Who Did Not Match Into Orthopedic Surgery
| Orthopedics matches that developed interest in orthopedics during medical school vs. non-orthopedics matches | M1 | M2 | M3 | M4 | Match |
|---|---|---|---|---|---|
| OR | OR | OR | OR | OR | |
| (95% CI) | (95% CI) | (95% CI) | (95% CI) | (95% CI) | |
| Male | 1.02 (0.271.02 -3.85) | ||||
| White | 1.34 (0.281.34 -6.42) | ||||
| Family in medicine | 0.20 (0.0110.20 -3.44) | ||||
| Family in Orthopedics | 4.90 (0.254.90 -95.16) | ||||
| Married | 0.73 (0.090-5.88) | 0.75 (0.14-4.19) | 1.41 (0.27-7.37) | 4.09 (0.67-24.95) | 0.92 (0.20-4.25) |
| Children | 3.68 (0..44-31.07) | 5.63 (1.00-31.75) | 2.57 (0.30-22.15) | 2.55 (0.29-22.71) | 0.86 (0.010-7.37) |
| Mentor | 1.60 (0.32-8.12) | 2.66 (0.48-14.69) | 3.08 (0.59-16.05) | 9.48 (0.53-169.58) | 1.49 (0.30-7.30) |
| Mentor in Orthopedics | 61.86 (7.60-503.85) | 5.45 (0.60-49.21) | 14.36 (2.51-82.32) | 163.00 (17.40-1527.1) | 125.68 (23.38-675.59) |
| Research | 5.17 (0.64-41.67) | 3.70 (0.43-31.95) | 6.24 (0.74-52.29) | 3.12 (0.28-34.98) | 2.58 (0.30-21.80) |
| Research in Orthopedics | 2.93 (0.35-24.82) | 10.02 (1.74-57.71) | 12.00 (2.54-56.69) | 5.00 (0.51-48.96) | 1446 (80.54-25961) |
| Debt from undergrad | 1.27 (0.341.27 -4.82) | ||||
| Debt from medical school | 1.46 (0.18-11.87) | 1.00 (0.12-8.72) | 0.48 (0.091-2.51) | 0.70 (0.077-6.42) | 2.71 (0.14-50.97) |
| Debt affects specialty choice | 1.41 (0.37-5.33) | 3.21 (0.58-17.72) | 1.16 (0.26-5.27) | 2.76 (0.45-16.76) | 3.80 (0.39-37.06) |
Bolded values denotes statistical significance of p <0.05
Cost of Matching into Orthopedics
The total programs applied to, interview invites received, and interviews attended was significantly higher for matched orthopedic applicants, as compared to other specialties with 82.3, 23.2 and 15.6 compared to 36.9, 16.4, 12.3 (p-values=<0.001, 0.009, and 0.003) (Table 8). The average cost for application fees, interview expenses, and total cost for a matched orthopedic surgery applicant was significantly higher than other specialties (Table 8); $1,818.80, $7,020, and $8,838.80 compared to $638.50, $5,535.00, and $6,173.40 (p-values= <0.01, 0.009, and 0.007) (Table 8).
Table 8.
Number of Programs Applied to, Interview Invites Received, Interviews Attended, Rank List and the Cost Associated With Them For Orthopedic Surgery Matches Compared to Non-Orthopedic Matches Students
| Orthopedics Match (std dev) Cost ($) N=16 | Non-orthope- dics Match (std dev) Cost N=277 | P-value | |
|---|---|---|---|
| Programs applications | 82.3 (17.0) $1818.80 | 36.9 (20.7) $638.40 | <0.001 <0.001 |
| Interviews received | 23.2 (8.6) - | 16.4 (8.0) - | 0.009 |
| Interviews attended | 15.6 (3.6) $7,020.00 | 12.3 (4.7) $5,535.00 | 0.003 0.009 |
| Total Cost | $8,838.80 | $6,173.40 | 0.007 |
Bolded values denotes statistical significance of p <0.05
Discussion
Consistent with current literature mentorship and research,7,25 the impact factors which correlated most with choosing and matching into orthopedic surgery as a specialty are research and mentorship. This study is continuation of a 2017 paper by Berger et al. evaluating trends factors for interest in surgical specialties, but that paper had a small sample size and did not follow the participants until the match process and graduation. Therefore, the current manuscript specifically looks at orthopedic surgery applicants compared to their peers that have all gone through the match process and includes four times the number of study participants. The current study revealed that students who successfully match into orthopedic surgery are involved in research, particularly in their second and third years of medical school. Interestingly, the research does not seem to necessarily be within the field of orthopedic surgery, as students who matched into orthopedic surgery were more likely doing research in any specialty. However, there was a significantly higher likelihood of students who match into orthopedic surgery doing orthopedic surgery research during their M2, M3, M4 years and continuing through the match process. These students also tended to have orthopedic mentors all throughout medical school. Factors unrelated to pursuing orthopedic surgery on any of the surveys were marital status or having children. Consistent with published literature,18 the first 4 surveys showed burden of debt from undergrad or medical school did not influence students to pursue orthopedic surgery, nor did being married or having children. However, at the match survey, students who matched into orthopedic surgery stated the debt from medical school did influence their decision. Their debt level may have been affected by the cost of applying to the orthopedic surgery match.
Many students decide early on, possibly even before medical school, they want to pursue orthopedic surgery.18 We found many students knew they wanted to pursue orthopedics prior to medical school, but the majority (52.4%) who matched into orthopedic surgery became interested during medical school. Even though interest in a specialty has been shown to be associated with the clerkship experience in that specialty,27 many schools do not require students to complete an orthopedic surgery rotation.8 However, in 2005 the AAMC issued requirements for musculoskeletal education such as disease processes and physical exam be incorporated in the curriculum, but they did not mandate a clinical clerkship in orthopedic surgery. Therefore, opportunities for students to be involved with research and mentorship must be available to all students, starting at the beginning of medical school in order to get exposure to the specialty. These factors may be even more evident for female students, as they were the only demographic significantly under-represented in the group who matched into orthopedic surgery and have been shown to be more influenced by clerkship experiences, rather than experiences before medical school.18
There are only minor differences between students who were interested in orthopedic surgery in medical school, yet matched into another specialty, and the ones who matched into orthopedic surgery. Students who do not match into orthopedic surgery were more likely to have performed research in fields other than orthopedic surgery before medical school. They were also less likely to have an orthopedic surgery mentor during the M4 and match survey and were less likely to be doing research at the time of the match survey (Table 3). This further supports the hypotheses that many students have predetermined their specialty choice, prior to starting medical school. Subsequently, this highlights the importance of any early exposure to orthopedics, prior to medical school. One potential, confounder in these results is students that applied to and were unsuccessful in matching into an orthopedic surgery residency program. We are unable to make conclusions on this possible occurrence since the survey only asked what specialty they matched into and if they applied to multiple specialties but did not specifically ask which specialties they applied to, if it was multiple.
Conversely and more likely importantly, the students who initially did not report an interest in orthopedics on their M1 surveys but ultimately matched into it were associated with mentorship by an orthopedic surgeon during the M1, M3, M4, and Match time points and research in orthopedics during the M2, M3, and Match surveys Table 7). These further highlight importance of early exposure to orthopedic surgery through mentorship and providing research opportunities even to students who may not appear to have an initial interest in orthopedics. We are unable to definitively conclude how much affect the specialty of a mentor has on the student. However, these findings support the notion that a mentor’s specialty likely affects the future career choice of the students they are mentoring to some degree. Alternatively, it is certainly possible that the students are searching out mentors and research project on their own. However, during the M1, and M2 surveys students have not completed any clinical rotations including rotations in orthopedic surgery to allow them to get to know and to work with orthopedic surgeons. Therefore, we suggest that the specialty of mentors has some effect on students’ future career choice, but the exact amount is unknown and likely depends on each mentor and student. It has been demonstrated by Anderson et al. that exposure to surgical fields early in medical school increases interest and likelihood of matching into surgical specialtie,4 but there is currently no literature evaluating the effect that mentors have on students’ career choice.
The number of orthopedic surgery residency programs applicants are applying to has consistently increased over the past few decades,13 leading to increased costs, as application fees are $99 for 1-10 programs, then $16 for each program between 11-20, then $20 for each program between 21-30, and then each application beyond 30 costs $26 each.3 This fee schedule is designed to deter applicants from applying to more programs than necessary. However, it does not seem to be effective, as we found orthopedic applicants are applying to 82.3 programs. Compare this to their classmates entering other medical specialties, who are applying to a mean of 36.9 programs. In other words, it costs the average applicant who matches into orthopedics surgery $1,818.80 to apply for residency, while applications for matching to other specialties cost an average of $638.40. More applications lead to more interviews being offered and more interviews being attended, thus further increasing the cost of matching into orthopedic surgery. These numbers are excellent reference points in the light of recent concerns for further increases of applications by applicants due to less time constraints to conduct virtual interviews due to COVID-19 pandemic in the 2020-2021 interview season. With the potential continuation of this model this paper may become a reference for determining how to proceed.15 Matched orthopedic surgery applicants in this study received an average of 23.2 interview invites, of which they attended 15.6. While applicants entering other specialties, received 16.4 interview invites and attended 12.3. Therefore, using the mean cost estimate for attending a single interview of $450,14 the average orthopedic surgery applicant spent $7,020.00 on interview expenses compared to $5,535.00 for applicants of other specialties. Bringing the total cost of matching into an orthopedic surgery residency position to $8,838.80, compared to $6,173.40 for other applicants. A recent study found that it costed their interviewees $0 participate in their virtual interview during the COVID-19 pandemic.6 With proposed continuation of virtual interviews31 the data presented in this manuscript is an invaluable resource for program directors and coordinators to be able to evaluate the effects of any changes they are considering to their application and interview process as well as governing bodies when determining the future recommendations.
The effort to combat increased expenses of applying for orthopedic surgery residency is two-fold, students can and should get involved in research and mentorship in medical school. As it has been shown that less competitive applicants apply to more programs and do more costly away rotations.13 Additionally, programs can be more transparent on with their historical averages for grades, scores, and research involvement, thus allowing applicants to be more selective and only apply to programs where they are competitive. This will decrease the application burden on program directors and will allow for a more thorough review of each application.19 This is imperative as the USMLE step 1 exam moves to pass/fail,2 thus removing one variable used for interview selection. A majority of program directors in neurosurgery report that making USMLE Step 1 pass/fail will make objective evaluation of residency candidates more difficult and will increase the weight put on USMLE Step 2 and medical school reputation.16 Consequently, the best way to decrease application expenses is to decrease the number of unnecessary applications, thus allowing residency programs a more thorough and careful selection process to match their program’s mission.
There are some minor limitations with this paper. Due to the fact that this study was conducted with the graduating classes of 2017-2020 with conclusion of data collection in May 2020 we are unable to evaluate the impact of COVID-19 on the residency application and interview process, however since the data collected was not altered by the pandemic it serves as an excellent resource for future research and planning of upcoming cycles. Also, due to the observational design of the study, we cannot definitively conclude causality with this study, such as students who perform research in orthopedic surgery are more likely to be interested in orthopedic surgery versus students who are interested in orthopedic surgery are more likely to perform research in orthopedic surgery. Any data discrepancies are due to participants choosing not to answer certain survey questions. There is potential sampling bias, due to only surveying students in one medical school and the overall small number of students matching into orthopedic surgery. This was minimized by surveying multiple classes and pooling the results. This study does not identify students who applied for but did not match into orthopedic surgery. Those students were counted with the specialty they ultimately matched into or positions obtained using the SOAP process. Therefore, we are unable to compare students who applied to and matched orthopedic surgery and those that applied for and were not successful in matching into orthopedic surgery. Despite the significant findings from this study, minimal differences between the students who matched into orthopedic surgery and the students who were planning to specialize in orthopedic surgery but matched into a different specialty suggest there are other variables, such as grades and USMLE scores, determining whether students pursue and match into orthopedic surgery. A future area of study would be to evaluate students that successfully matched into orthopedic surgery compared to those that applied but did not match as this would allow us to identify characteristics and experiences that influence a successful match. As this study did not explicitly ask what other specialties a student had applied to.
This study provides longitudinal insight into medical students pursuing a career in orthopedic surgery. Although many students who match into orthopedic surgery know they are interested in the specialty prior to medical school, a significant number of students still become interested during these formative years. Despite these differences, the students who matched into orthopedic surgery are doing research and have mentors within the specialty at multiple time points throughout medical school, particularly early on. Building on these factors and increasing the transparency of the residency match process can help reverse the trend of increasing application and interview numbers in light of possible continuation of virtual interviews. This would aid both applicants and programs, alike, streamlining the match process and decreasing the financial strain.
Appendix
Table A.
Survey Responses For All Study Participants
| Study demographics | M1 (%) | M2 (%) | M3 (%) | M4 (%) | MATCH (%) |
|---|---|---|---|---|---|
| Age at matriculation | 23.62 STD DEV=2.34 | ||||
| Male | 299 (55.9) | ||||
| Female | 236 (44.1) | ||||
| Ethnicity is White | 373 (75.4) | ||||
| Ethnicity is Non-White | 122 (24.6) | ||||
| Ethnicity is African American | 14 (2.83) | ||||
| Ethnicity is Asian | 81 (16.4) | ||||
| Ethnicity is Hispanic | 27 (5.45) | ||||
| Married | 78 (14.6) | 190 (39.4) | 77 (21.1) | 81 (27.5) | 98 (44.3) |
| Not married | 458 (85.4) | 292 (60.6) | 288 (78.9) | 214 (72.5) | 123 (55.7) |
| No children | 517 (96.4) | 440 (91.7) | 343 (94.0) | 314 (92.3) | 163 (83.6) |
| At least 1 child | 19 (3.54) | 40 (8.3) | 21 (6.0) | 26 (7.6) | 32 (16.4) |
| 1 Child | 12 (63.2) | 31 (77.5) | 12 (57.1) | 10 (38.4) | 17 (53.1) |
| 2 Children | 6 (31.6) | 8 (19.0) | 7 (33.3) | 14 (53.8) | 14 (43.8) |
| Greater than 2 children | 1 (5.26) | 1 (2.38) | 2 (9.52) | 2 (7.7) | 1 (3.1) |
| Family in medicine | 113 (21.1) | ||||
| No family in medicine | 423 (78.9) | ||||
| Family in Orthopedics | 38 (7.09) | ||||
| No family in Orthopedics | 498 (92.9) | ||||
| Mentor | 74 (17.0) | 209 (43.5) | 192 (45.6) | 202 (58.4) | 275 (70.9) |
| No mentor | 361 (83.0) | 271 (56.5) | 229 (54.4) | 144 (41.6) | 113 (29.1) |
| Mentor in Orthopedics | 2 (0.460) | 17 (3.54) | 16 (3.8) | 16 (4.7) | 18 (4.63) |
| No mentor in Orthopedics | 433 (99.5) | 462 (96.5) | 405 (96.2) | 328 (95.3) | 370 (95.4) |
| Research | 330 (61.6) | 280 (58.5) | 212 | 87 (39.9) | 183 (71.2) |
| No research | 206 (38.4) | 199 (41.6) | 211 | 131 (60.1) | 74 (28.8) |
| Research in Orthopedics | 31 (5.78) | 30 (6.9) | 31 (8.0) | 13 (6.0) | 14 (5.44) |
| No research in Orthopedics | 498 (92.9) | 446 (93.1) | 389 (92.0) | 202 (94.0) | 243 (94.6) |
| Yes, debt from undergrad | 205 (38.2) | 154 (37.8) | 155 (37.0) | 101 (38.0) | 104 (50.0) |
| No, debt from undergrad | 331 (61.8) | 253 (62.2) | 264 (63.0) | 165 (62.0) | 104 (50.0) |
| Yes, debt from med school | 451 (84.1) | 342 (84.2) | 351 (83.4) | 292 (84.6) | 239 (77.3) |
| No, debt from med school | 85 (15.9) | 64 (15.8) | 70 (16.6) | 53 (15.4) | 70 (22.7) |
| Yes, debt impact on choice | 191 (36.2) | 152 (37.5) | 160 (39.2) | 125 (36.9) | 114 (45.4) |
| No, debt impact on choice | 336 (63.8) | 253 (62.2) | 248 (60.9) | 214 (63.1) | 137 (54.6) |
| Selected Orthopedics for that survey | 39 (7.28) | 38 (7.93) | 26 (6.13) | 17 (4.9) | 22 (5.08) |
| Did not select Orthopedics for that survey | 497 (92.7) | 441 (92.1) | 398 (93.6) | 331 (95.1) | 411 (94.9) |
| Total responses | 536 | 482 | 425 | 348 | 433 |
Table B.
Survey Responses For All Students That Matched Into Orthopedics
| Orthopedic Matches Demographics | M1 (%) | M2 (%) | M3 (%) | M4 (%) | MATCH (%) |
|---|---|---|---|---|---|
| Age at Matriculation (Std dev) | 23.73 (2.80) | ||||
| Male | 15 (78.9) | ||||
| Female | 4 (21.1) | ||||
| Ethnicity is White | 16 (88.9) | ||||
| Ethnicity is Non-White | 2 (11.1) | ||||
| Ethnicity is African American | 0 (0.0) | ||||
| Ethnicity is Asian | 1 (50.0) | ||||
| Ethnicity is Hispanic | 1 (50.0) | ||||
| Married | 2 (10.5) | 5 (31.2) | 4 (26.7) | 4 (50.0) | 5 (33.3) |
| Not Married | 17(89.5) | 11 (68.8) | 11 (73.3) | 4 (50.0) | 10 (66.7) |
| No children | 17 (89.5) | 12 (75.0) | 13 (86.7) | 7 (77.8) | 13(86.7) |
| At least 1 child | 2 (10.5) | 2 (12.5) | 2 (13.3) | 2 (22.2) | 2 (13.3) |
| 1 child | 0 (0.0) | 1 (50.0) | 0 (0.0) | 0 (0.0) | 0 (0.00) |
| 2 children | 2 (100.0) | 1 (50.0) | 2 (100.0) | 2 (100.0) | 1 (50.0) |
| Greater than 2 children | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (50.0) |
| Family in medicine | 5 (26.3) | ||||
| No family in medicine | 14 (73.7) | ||||
| Family in orthopedics | 2 (10.5) | ||||
| No family in orthopedics | 17 (89.4) | ||||
| Mentor | 2 (12.5) | 10 (62.5) | 10 (66.7) | 7 (77.8) | 18 (85.7) |
| No mentor | 14 (87.5) | 6 (37.5) | 5 (33.3) | 2 (22.2) | 3 (14.3) |
| Mentor in Orthopedics | 2 (12.5) | 5 (31.3) | 5 (33.3) | 6 (66.7) | 18 (85.7) |
| No Mentor in Orthopedics | 14 (87.5) | 11 (68.8) | 10 (66.7) | 3 (33.3) | 3 (14.3) |
| Research | 6 (31.6) | 14 (87.5) | 12 (80.0) | 5 (62.5) | 14 (93.3) |
| No Research | 13 (68.4) | 2 (1.25) | 3 (20.0) | 3 (37.5) | 1 (6.67) |
| Research in Orthopedics | 2 (10.5) | 8 (50.0) | 7 (46.7) | 3 (37.5) | 13 (86.7) |
| No Research in Orthopedics | 17 (89.5) | 8 (50.0) | 8 (53.3) | 5 (62.5) | 2 (13.3) |
| Yes, debt from undergrad | 6 (31.6) | ||||
| No, debt from undergrad | 13 (68.4) | ||||
| Yes, debt from med school | 14 (73.7) | 10 (62.5) | 10 (66.7) | 8 (72.7) | 12 (85.7) |
| No, debt from med school | 5 (26.3) | 6 (37.5) | 5 (33.3) | 3 (33.3) | 2 (14.3) |
| Yes, debt impact on choice | 7 (38.9) | 7 (43.8) | 6 (40.0) | 3 (33.3) | 9 (69.2) |
| No, debt impact on choice | 11 (61.1) | 9 (56.3) | 9 (60.0) | 8 (72.7) | 4 (30.8) |
| Selected orthopedics for that survey | 10 (52.6) | 11 (68.8) | 8 (53.3) | 8 (88.9) | 22 (100.0) |
| Did not select Orthopedics for that survey | 9 (47.4) | 5 (31.25) | 7 (46.7) | 1 (11.1) | 0 (0.00) |
| Total Responses | 19 | 16 | 15 | 11 | 22 |
Table C.
Survey Responses For All Students That Were Stated They Were Pursuing Orthopedics at Some Point During Medical School But Matched Into Another Specialty
| Non-orthopedic Matches that were interested in orthopedic in medical school Demographics | M1 (%) | M2 (%) | M3 (%) | M4 (%) | MATCH (%) |
|---|---|---|---|---|---|
| Age at Matriculation | 23.55 (std dev=2.28) | ||||
| Male | 36 (72.0) | ||||
| Female | 14 (28.0) | ||||
| Ethnicity is White | 37 (77.1) | ||||
| Ethnicity is Non-White | 11 (22.9) | ||||
| Ethnicity is African American | 1 (9.1) | ||||
| Ethnicity is Asian | 6 (54.5) | ||||
| Ethnicity is Hispanic | 4 (36.3) | ||||
| Married | 8 (15.7) | 25 (55.6) | 13 (35.1) | 11 (28.9) | 7 (33.3) |
| Not Married | 43 (84.3) | 20 (44.4) | 24 (64.9) | 27 (71.1) | 14 (66.7) |
| No children | 49 (96.0) | 41 (91.1) | 33 (89.2) | 35 (92.1) | 18 (90.0) |
| At least 1 child | 2 (4.00) | 4 (8.90) | 4 10.8) | 3 (7.9) | 2 (10.0) |
| 1 child | 2 (100.0) | 3 (75.0) | 2 (50.0) | 0 (0.0) | 1 (50.0) |
| 2 children | 0 (0.00) | 1 (25.0) | 2 (50.0) | 3 (100.0) | 1 (50.0) |
| Greater than 2 children | 0 (0.00) | 0 (0.00) | 0 (0.00) | 0 (0.0) | 0 (0.00) |
| Family in medicine | 12 (23.5) | ||||
| No family in medicine | 39 (76.5) | ||||
| Family in orthopedics | 1 (1.96) | ||||
| No family in orthopedics | 50 (98.0) | ||||
| Mentor | 4 (8.89) | 24 (53.3) | 21 (56.8) | 23 (67.6) | 25 |
| No Mentor | 41 (91.1) | 21 (46.7) | 16 (43.2) | 11(32.4) | 11 |
| Mentor in Orthopedics | 0 (0.00) | 10 (22.2) | 11 (29.7) | 8 (23.5) | 0 (0.00) |
| No Mentor in Orthopedics | 45 (100.0) | 35 (77.8) | 26 (70.2) | 26 (76.5) | 36 (100.0) |
| Research | 33 (64.7) | 28 (62.2) | 28 (75.7) | 11 (64.7) | 18 |
| No Research | 18 (35.3) | 17 (37.8) | 9 (24.3) | 6 (35.3) | 8 |
| Research in Orthopedics | 12 (23.5) | 13 (28.9) | 15 (40.5) | 5 (28.4) | 1 |
| No Research in Orthopedics | 39 (76.5) | 32 (71.1) | 22 (59.5) | 12 (70.6) | 35 |
| Yes, debt from undergrad | 14 (27.5) | ||||
| No, debt from undergrad | 37 (72.5) | ||||
| Yes, debt from med school | 43 (84.3) | 35 (77.8) | 27 (73.0) | 22 (68.7) | 21 (87.5) |
| No, debt from med school | 8 (15.7) | 10 (22.2) | 10 (27.0) | 10 (31.3) | 3 (12.5) |
| Yes, debt impact on choice | 20 (40.0) | 20 (44.4) | 13 (39.4) | 9 (30.0) | 7 (41.2) |
| No, debt impact on choice | 30 (60.0) | 25 (55.6) | 20 (60.6) | 21 (70.0) | 17 (70.8) |
| Selected orthopedics for that survey | 29 (56.9) | 27 (60.0) | 18 (48.6) | 9 (25.0) | 0 (0.00) |
| Did not select Orthopedics for that survey | 22 (43.1) | 18 (40.0) | (51.4) | 27 (75.0) | 37 (100.0) |
| Total Responses | 51 | 45 | 37 | 36 | 37 |
Table D.
Survey Responses For Students That Matched Into a Specialty That Was Not Orthopedics
| All non-orthopedic matches demographics | M1 (%) | M2 (%) | M3 (%) | M4 (%) | MATCH (%) |
|---|---|---|---|---|---|
| Age at Matriculation | 23.57 (std dev=2.50) | ||||
| Male | 284 (54.9) | ||||
| Female | 232 (44.9) | ||||
| Ethnicity is White | 357 (69.1) | ||||
| Ethnicity is Non-White | 120 (23.2) | ||||
| Ethnicity is African American | 14 (11.7) | ||||
| Ethnicity is Asian | 80 (66.7) | ||||
| Ethnicity is Hispanic | 26 (21.7) | ||||
| Married | 76 (14.7) | 185 (39.7) | 91 (22.1) | 77 (26.8) | 93 (44.5) |
| Not Married | 441 (85.3) | 281 (60.3) | 320 (77.9) | 210 (73.2) | 115 (55.5) |
| No children | 500 (96.7) | 428 (91.8) | 385 (93.9) | 306 (92.7) | 154 (83.7) |
| At least 1 child | 17 (3.3) | 38 (8.15) | 25 (6.1) | 24 (7.3) | 30 (16.3) |
| 1 child | 11 (64.7) | 33 (86.8) | 12 (57.1) | 10 (41.7) | 15 (50.0) |
| 2 children | 4 (23.5) | 5 (13.2) | 11 (91.8) | 12 (50.0) | 11 (36.7) |
| Greater than 2 children | 2 (11.8) | 0 (0.00) | 1 (8.2) | 2 (8.3) | 4 (13.3) |
| Family in medicine | 108 | ||||
| No family in medicine | 409 | ||||
| Family in orthopedics | 5 (0.97) | ||||
| No family in orthopedics | 512 (99.0) | ||||
| Mentor | 72 (17.2) | 199 (42.9) | 182 (44.8) | 195 (57.9) | 257 (70.0) |
| No mentor | 347 (83.2) | 265 (57.1) | 224 (55.2) | 142 (42.1) | 110 (30.0) |
| Mentor in Orthopedics | 2 (0.46) | 17 (3.54) | 11 (2.7) | 10 (3.0) | 0 (0.00) |
| No mentor in Orthopedics | 433 (99.5) | 463 (96.5) | 395 (97.3) | 326 (97.0) | 367 (100.0) |
| Research | 314 (60.7) | 266 (57.5) | 200 (49.0) | 82 (39.0) | 169 (69.8) |
| No Research | 203 (39.3) | 197 (62.5) | 208 (51.0) | 128 (61.0) | 73 (30.2) |
| Research in Orthopedics | 24 (4.60) | 22 (4.75) | 24 (5.9) | 10 (4.8) | 1 (0.41) |
| No Research in Orthopedics | 493 (95.4) | 441 (95.2) | 384 (94.1) | 200 (95.2) | 241 (99.6) |
| Yes, debt from undergrad | 199 (38.5) | ||||
| No, debt from undergrad | 318 (41.5) | ||||
| Yes, debt from med school | 437 (84.5) | 398 (83.3) | 341 (84.0) | 284 (85.0) | 227 (76.9) |
| No, debt from med school | 80 (15.5) | 80 (16.7) | 65 (16.0) | 50 (15.0) | 68 (23.1) |
| Yes, debt impact on choice | 184 (35.6) | 183 (38.4) | 154 (38.2) | 112 (34.1) | 105 (44.1) |
| No, debt impact on choice | 325 (62.9) | 294 (61.6) | 239 (60.8) | 206 (65.9) | 133 (55.9) |
| Selected orthopedics for that survey | 29 (5.6) | 27 (5.83) | 18 (4.4) | 9 (2.7) | 0 (0.00) |
| Did not select Orthopedics for that survey | 488 (94.4) | 436 (94.2) | 391 (5.6) | 330 (97.3) | 411 (100.0) |
| Total Responses | 517 | 482 | 411 | 339 | 411 |
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