Another technological change requested by residents is the creation and updating of fellowship web pages with standardized information. Such a service may prove useful to residents researching a program and may even lead to limiting the number of programs residents apply to, as they may be able to dial in on exactly what distinguishes one program from another before traveling for an interview. A recent study of orthopedic sports medicine fellowship programs found that most of these programs lacked pertinent information on their websites.18 Important information regarding case logs from current and former fellows; number of faculty, residents, and fellows; and schedules and facilities of interview sites are a few of the online data points that may help residents differentiate particular programs.19,20 Questions like these are often asked at interviews and site visits. Having accurate information easily available online may reduce or eliminate the need to travel to a site for such information. Standardizing information would also increase transparency among available fellowships. Although not specifically mentioned, organizational software that improves the productivity of the process may help limit the large number of programs applied to, the interviews offered and attended, the days away, and the financial costs without reducing the match rate.
Timing and Location
The issue of timing—with respect to geographical or meteorological concerns—was another recurring theme among respondents. Numerous respondents indicated that certain programs located in geographic proximity tried to minimize travel by offering interviews around the same time. This coordination potentially minimizes travel expenses and time away from the residency program by allowing residents to interview at multiple locations during a single trip per region. The sports medicine fellowship process was identified as a good example of aligning interviews based on geography. Several respondents suggested an option that also reflects the practice of nonsurgical fellowships—delaying the interview season to bypass potential weather concerns. Winter 2013–2014 saw the most flight delays or cancellations in more than a decade; about 50% of all flights scheduled between December and February were delayed or canceled.21 Beyond the additional factor of more time away or missing an interview because of the weather are safety concerns related to the weather. One resident reported having a motor vehicle accident while traveling to an interview in poor weather conditions (Appendix).
National Meetings
Each orthopedic subspecialty has numerous national meetings. Many programs offer applicants the opportunity to interview at these meetings. One respondent mentioned that the annual meeting of the Orthopaedic Trauma Association offers trauma applicants the opportunity to interview with multiple programs. It might be beneficial to endorse this practice on a larger scale to help reduce travel and time away. We recognize that visiting individual programs is an important aspect of the match process, but doing so on a targeted level may make more sense, increasing financial efficiency and reducing time away from programs.
Proposed Solution
A combined proposed solution that can be implemented without a radical overhaul or significant investments might involve moving the interview season to early spring, switching to a 2-tiered system with a centralized first round of interview screening coinciding with subspecialty national meetings or the AAOS annual meeting, and standardizing online information for all orthopedic fellowship programs. A 2-tiered interview process would allow programs and candidates to obtain exposure to a significant number of programs in the first round without incurring significant costs and then would impose a cap on the number of programs to visit. This would level the playing field between candidates with more time and money and candidates who are more constrained in their training environment and finances. A stopgap or adjunct to residents or fellowship programs unable to attend a centralized meeting would be to combine technological tools, such as Internet-based videoconferencing (Skype), before site visits by residents. After this first round of introductions and interviews, residents could then decide on a limited number of programs to formally visit, attend, and ultimately rank. This proposed system would still be able to function within the confines of the match, and it would benefit from the protections offered to residents and programs. Although capping the number of interviews attended by residents clearly can lower costs across the board, we recognize the difficulty of enforcing such a requirement. These potential changes to the system are not exhaustive, and we hope this work will serve as a springboard to further discussion.
Our study had several inherent weaknesses. Our data came from survey responses, which reflect the perspectives only of the responding residents and program directors. Unfortunately, a small number of orthopedic residents responded to this survey, so there was a potential for bias. However, we think the central themes discovered in this survey are only echoes of the concerns of the larger population of residents and program directors. Our hope in designing such a study was to bring to light some of the discrepancies in the fellowship interview process, the goal being to stimulate interest among the orthopedic leadership representing future orthopedic surgeons. More study is needed to clarify if these issues are reflective of a larger segment of residents and program directors. In addition, action may be needed to fully elucidate the intricate interworking of the fellowship process in order to maximize the interest of the orthopedic surgeons who are seeking fellowship training. Another study limitation was the potential for recall bias in the more senior PGY-5 residents, who were further from the interview process than PGY-4 respondents were. Because of the need for anonymity with the surveys, we could not link some findings (eg, program impact, cost, time away) to individual programs or different specialty fellowships. Although it appears there is a desire for a more cost-effective system, given the financial pressures on medical students and residents, the desire to match increases costs because students are likely to attend more interviews than actually needed. Our proposed solution does not take into account residents’ behavior with respect to the current match system. For example, the prevailing thought is that interviewing at more programs increases the likelihood of matching into a desired subspecialty. Despite these study limitations, we think our results identified important points for discussion, investigation, and potential action by orthopedic leadership.