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Factors to Consider when Considering a Fellowship

Bernstein, Joseph

Section Editor(s): Bernstein, Joseph MD, Guest Editor

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 215-217
doi: 10.1097/01.blo.0000224071.08535.b7
SECTION I: SYMPOSIUM III: Orthopaedic Fellowships
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From the *University of Pennsylvania, Department of Orthopaedic Surgery, and the †Veterans Hospital, Philadelphia, PA.

Correspondence to: Joseph Bernstein, MD, 424 Stemmler Hall, University of Pennsylvania, Philadelphia, PA 19104. Fax: 215-754-4214; E-mail: orthodoc@post.harvard.edu.

There are many factors to consider when contemplating a fellowship training program, but first among them is that fellowship training is optional. Although there are some career paths for which additional training is clearly mandatory-oncology and hand surgery come to mind-a graduating chief resident should be very employable as a general orthopaedic surgeon without a 6th year of postgraduate education. And remember: fellowship education has the highest tuition of any schooling you will receive. This cost must be mentioned explicitly, as the tuition is paid only implicitly as an “opportunity cost,” namely, the money you could have earned by entering practice and foregoing this extra year of education.

You may do well to consider participating in fellowship training as a business transaction. You, the trainee, should get three things: specific orthopaedic skills, a diploma signifying the acquisition of these skills, and access to a network of like-minded professionals. These can be summarized as the three Cs: capabilities, credentials, and contacts. In return, you cede the opportunity to earn at least $100,000 in pay, a sum greater than four years of tuition at some medical schools. If the three Cs are not worth $100 Gs, you should skip fellowship training and begin your independent practice.

Once you have decided to take an additional year of training, you have to select a field of subspecialization and the institution at which you will receive your education. To help you, Clinical Orthopaedics and Related Research has compiled this guide to fellowships, which includes a roster of fellowship training programs. This list is provided by the American Academy of Orthopaedic Surgeons, courtesy of a grant from Stryker. Additionally, a series of short essays, one for each field, has been composed by the following knowledgeable orthopaedic experts.

  • Arthritis and Joint Reconstruction: Arlen Hanssen, MD
  • Dr. Hanssen is Professor of Orthopaedic Surgery at the Mayo Clinic. He has been the Program Director for the Mayo Orthopaedic Surgery Residency since 1998 and is one of the participating attending physicians in the Mayo Clinic Lower Extremity Adult Reconstruction Fellowship.
  • Foot and Ankle: Shepard R. Hurwitz, MD
  • Dr. Hurwitz is Professor of Orthopaedic Surgery at the University of Virginia and Head of the Foot and Ankle Division. He completed a fellowship in foot and ankle surgery at The Hospital for Special Surgery. He has supervised clinical and research fellows in foot and ankle surgery and has served as residency director at three major teaching centers.
  • Hand: Martin I. Boyer, MD
  • Dr. Boyer is Associate Professor of Orthopaedic Surgery at Washington University, where he is Chief of the Hand Service. He completed a trauma fellowship at the University of Toronto and a hand fellowship at the Indiana Hand Center in Indianapolis.
  • Musculoskeletal Oncology: Mathew R. DiCaprio, MD
  • Dr. DiCaprio is Clinical Assistant Professor of Orthopaedic Surgery at Albany Medical College. He completed his musculoskeletal oncology fellowship at the University of Florida.
  • Pediatric Orthopaedics: John P. Dormans, MD
  • Dr. Dormans is Chief of Orthopaedic Surgery at the Children's Hospital of Philadelphia and Professor of Orthopaedic Surgery at the University of Pennsylvania School of Medicine. He completed a pediatric orthopaedic fellowship at The Hospital for Sick Children in Toronto. He specializes in pediatric spinal deformity and musculoskeletal tumors.
  • Research: Jaimo Ahn, MD, PhD
  • Dr. Ahn completed a fellowship in genetic and molecular orthopaedics at the University of Pennsylvania School of Medicine.
  • Shoulder and Elbow: Joseph P. Iannotti, MD, PhD
  • Dr. Iannotti is the Maynard Madden Professor of Orthopaedic Surgery at the Cleveland Clinic, where he is also Chairman of the Department of Orthopaedic Surgery. Heis currently President of the American Shoulder and Elbow Surgeons society.
  • Spine: Kevin F. McGuire, MD
  • Dr. McGuire is a spine surgeon at Beth Israel Deaconess Medical Center/Harvard Medical School. He completed his spine fellowship under Dr. Henry Bohlman at the University Hospitals in Cleveland.
  • Sports Medicine: Robert G. Marx, MD
  • Dr. Marx is Associate Professor of Orthopaedic Surgery and Public Health at Weill Medical College of Cornell University and Associate Attending Orthopaedic Surgeon at the Hospital for Special Surgery. He completed his fellowship training in sports medicine and shoulder surgery at the Hospital for Special Surgery.
  • Trauma: William G. DeLong, MD
  • Dr. DeLong is Professor of Orthopaedic Surgery and Chief of Orthopaedic Trauma at Temple University, where he is Director of the AO Trauma Fellowship. He also serves as team physician for the Philadelphia Flyers.

The essays that follow emphasize principles particularly applicable to the field they discuss. To preserve that focus, some comments of general interest are offered here and assembled into a set of ten rules. (More specific, but perhaps excessively rigid, guidelines are given in Table 1). This list is by no means definitive or exhaustive, but it should help start your search.

TABLE1

TABLE1

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#1: Know yourself

There is no optimal fellowship. Rather, all that can be optimized is the fit between what the fellowship offers and what you want. So your search begins by taking inventory of yourself. You may be asked at an interview, “Where do you want to be in ten years?” As interview fodder, that question may sound hackneyed and banal-but like most clichés, it became overused only because it is so apt. You should have a clear sense of where you want to go before you invest heavily in a plan to get there. You must understand your motivations and future career plans. Equally important, frankly assess your strengths and weaknesses and be willing to address those weaknesses. Fellowship education is not an occasion to play to your strengths; there is plenty of time for that after training. The fellowship year is the last chance you will have for a supervised environment to work on improving what you do not yet do well.

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#2: Scrutinize the structure of the program

Even if your prime motivations for taking a fellowship are to remediate deficiencies and simply round out your education, you should aim for a fellowship that is more than just an extension of your residency. A good fellowship is designed to cultivate your clinical management skills and nurture critical thinking by giving you more opportunities for independent thinking. Because of the high opportunity costs-the implicit tuition-associated with participating in a fellowship, there should be only minimal service requirements. Your role at departmental conferences should be active; your job in the operating room should be to teach as well as to learn. Fellowship may be a 6th postgraduate year, but you must be more than a PGY-6.

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#3: Assess the track record

The past is not always prologue, but the best sense of what the fellowship training program will do for you comes from measuring what it has done for prior fellows. If you want an academic career, avoid those programs that send all of their graduates into private practice. If you want to reside in the area after training, you may be alerted to difficulties in doing so if all of the fellows before you have left town. Another important reason for studying the output of the fellowship training program is to see whether there is substantial overlap between what the fellowship director claims the fellowship program attempts to do and what it has done. Disparities are worrisome.

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#4: Glance (quickly) at what you will be paid

In general, you should be paid a little more than a 5th-year resident and receive some funds for books and travel. Minor differences in pay should not influence your choice. Nonetheless, a particularly low salary may be a red flag, suggesting indifference to a fellow's well being. Also note that in some big cities, you may need to supplement your salary (with borrowing, consumption of savings, or moon-lighting) to afford a place to live. Housing costs alone should not dissuade you from attending a big city program. Remember that the major expense, borne at all institutions regardless of salary or cost of living, is the opportunity cost of attending. If education in New York City or San Francisco is worth the $100,000 opportunity cost, it is probably worth the extra $20,000 in living expenses as well.

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#5: Find out if everybody plays nicely

A factionalized faculty is poisonous. When attending physicians bicker, you may feel forced to take sides-and acquire an enemy or two in the process. (This is precisely the opposite of your purpose, namely, the cultivation of supportive relationships.) Stay away from unhappy places! Also, look to see if the residents and fellows get along. There may be some conflict when the roles of the fellows and residents are not clearly defined in advance, especially if there is not enough clinical material for everybody.

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#6: Ask about on-call duties (“How good?” is more important than “How often?”)

Regarding night call, the analysis is simple. If the duties performed while on call are educational, night work is not only acceptable, it is desirable. If the duties are aggravating, you are better off without it. There may be a strong temptation to choose a program that has no on-call duties so you have the time to moonlight. That is not altogether unreasonable; however, you should recall that you are already paying in excess of $100,000 as an opportunity cost. Your mission is to learn as much as you can possibly learn in one year; to undermine that for a small salary supplement is silly.

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#7: Look for diversity

In the past, some very successful fellowship programs existed as one-on-one apprenticeships with a leading surgeon. In such a setting, you will have a chance learn from the master and become one of his disciples. On the whole, though, you will benefit more from diversity in the faculty. When there is a multitude of faculty members, you will have a greater selection from which to find a mentor. You will probably also learn a variety of approaches to solving a given clinical problem. (This is intrinsically valuable, but also offers the secondary benefit of reminding you that not everything is known with certainty.) The environment for critical thinking is fostered by diversity. Diversity is measured not only in pure numbers, but in the pedigree of the attendings as well: six attendings who were educated at the same institution may offer less diversity of thought than two surgeons with highly disparate backgrounds.

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#8: Investigate the research program

Unless you are exceptionally talented or exceptionally lucky, it is doubtful that you will make a major research contribution in one year. Thus, if you are going to do research as part of your fellowship, it is much more important to ask a good question than to try to offer a good answer. Learning to design a research protocol will enable you to be academically productive long after you complete the fellowship. To that end, you should investigate the research program of the fellowship. Look up on Medline what was produced. Was it any good? Was it uniquely suited to the institution and its clinical database? Did fellows from years ago continue to produce independently? These questions can be answered with specificity and without much effort. (Thank you, Google!)

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#9: Don't overpay for a brand name

There are really three potential markets for the credential you will acquire after fellowship: patients, orthopaedic surgeons in general, and colleagues within your chosen subspecialty. Each may have a different perception of the “brand name value” of the institution at which you train. Credentials from major universities-even if their orthopaedic department is weak-tend to impress patients. At the other end of the spectrum are fellowship training programs that have a justifiably top-notch reputation among other subspecialists, but whose brand name lacks any cachet in the larger market. If you are going to pay for a brand name-by sacrificing time, effort, comfort, money, the good graces of your spouse or partner, indeed anything-make sure this brand name will have value in the particular niche in which you wish to sell it and yourself.

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#10: Give credit for accreditation

If you want certification in hand surgery-and, eventually, sports medicine-you will need to train at an accredited fellowship program. Beyond that, certification can be considered optional. Still, all else being equal, an accredited fellowship program is better. The presence of accreditation is evidence the fellowship program has met some fairly high educational standards. Even if your field is one in which accreditation is fully optional, do not undervalue those fellowship training programs that have made the effort to obtain this mark of quality and commitment to education.

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Summary

These ten rules, along with the individual comments that follow, should help you consider your important career decisions. It is worth repeating: the goal is not to find the perfect fellowship training program, but to find one perfectly suited to you. And if all of the factors to consider must be condensed into one, the single most important feature of a given fellowship training program is that it has successfully prepared at least one prior fellow for a career path similar to what you want for yourself.

© 2006 Lippincott Williams & Wilkins, Inc.