The field of orthopaedic surgery has become increasingly subspecialized.1-3 A review of cases of orthopaedic surgeons taking Part II of the American Board of Orthopaedic Surgery Certification Examination revealed that fellowship-trained applicants increased from 76% in 2003 to 90% in 2013.2 The reasons for this trend toward additional training beyond residency likely are multifactorial and involve both macroeconomic forces and individual pressures.3,4 In addition, subspecialization may be an appropriate response to an expansion of knowledge and technology, a reduction in training hours, a desire for unity among those with shared interests, a perception that subspecialization improves patient care, and the demands of the subspecialty certification process.5
Greater subspecialization is also evident in other nonorthopaedic surgical specialties, including general surgery and obstetrics and gynecology.6,7 Regardless of the influences, the paradigm has shifted such that job opportunities for fellowship-trained orthopaedic surgeons have surpassed those for non–fellowship-trained orthopaedic surgeons.8 Evidence suggests that an orthopaedic surgery trainee’s return on investment in a year of fellowship training varies according to subspecialty.9 However, the factors that influence an orthopaedic surgery trainee’s selection of a specialty fellowship are not well understood.
The purpose of this study was to determine, on the basis of postgraduate year (PGY) level, whether variability exists in value assigned to certain factors when selecting a specific orthopaedic surgery subspecialty and to describe any trends in this variation. Identifying trends in these career choice influences may contribute to an improved understanding of the importance of various educational experiences over a training period and may guide future efforts toward curriculum development and career counseling.
We obtained approval from our Institutional Review Board before initiating this study. We used SurveyMonkey software to design an electronic survey. We selected this software because of its straightforward developer interface, widespread familiarity, and ease of survey distribution and data collection. The SurveyMonkey website provided guidance (eg, on timing, formatting, length) to optimize response rate.
We performed an English-language literature review to search for similar topics of fellowship specialty selection pertaining to training in orthopaedics as well as other medical fields, including radiology and surgery.1,10-14 On the basis of common themes in factors evaluated in these studies, which also may apply to orthopaedic surgery, we formulated a list of factors. Given that a similar study had not been reported previously in orthopaedic surgery, we queried attending orthopaedic surgeons, at our institution and other institutions, across a broad range of practice environments, about factors relevant to their selection of an orthopaedic surgery subspecialty. Other investigators have used similar techniques for survey design.1,11
On the basis of this background information, we designed a survey containing 14 discrete factors relevant to the selection of an orthopaedic surgery specialty fellowship. The survey asked respondents to rate each factor’s influence on their choice of fellowship by using a Likert scale rating (LSR) from 1 to 4,15 which has been validated for assessing levels of influence16 (Table 1). In addition, we requested demographic information, including PGY level, sex, and the geographic region of the training program.
Survey Distribution and Collection
The senior author (B.E.B.), the orthopaedic surgery residency program director at our institution, distributed surveys via email. Emails were sent to a list of all orthopaedic surgery residency and fellowship program coordinators nationally, whose email contacts were made available through the Accreditation Council for Graduate Medical Education (ACGME)17 website (n = 126). The email contained a brief description of the project’s purpose, a link to complete the survey, and a request that the email be forwarded to all trainees within the respective program. On the basis of the aggregate number of trainees included in the programs whose coordinators received emails, the total number of trainees who were eligible to complete the survey was approximately 1,932.
To ensure that only current trainees completed the survey, the email link provided the only portal for access to the survey website. An institutional email was required for each response to prevent multiple responses from the same individual; this email was unlinked from the response to de-identify study data. As an incentive for participation, trainees who completed all of the survey questions were entered into a random drawing for one of three $100 Amazon gift cards.
We compiled data from the SurveyMonkey website and exported the data to an Excel (Microsoft) spreadsheet, where we formatted it before statistical analysis. We used the Cochran-Mantel-Haenszel test to calculate Row Mean Scores Differ probabilities, a categorical analysis of variation in LSR scores based on PGY level. We compared junior trainees (PGY1 to PGY3) and senior trainees (PGY4+) by using a Student t-test. We considered a P value of <0.05 statistically significant for all comparisons, and we performed all analyses by using SAS version 9.4 (SAS Institute). For the purpose of discussion and comparison with previous studies, we categorized factors that differed significantly between junior and senior residents, such as lifestyle factors or intellectual factors, in a manner similar to that described in previous survey studies.1,11
We collected completed surveys from 359 trainees, including 15% to 20% in each of the PGY1 through PGY5 groups and approximately 10% of the PGY6+ group (Table 2). Of the respondents, 85.5% (n = 307) were men, and 14.5% (n = 52) were women. Every major region of the continental United States was represented, with respondents from the Southeast (33.7%, n = 121), Midwest (23.1%, n = 83), Northeast (20.9%, n = 75), Southwest (11.1%, n = 40), West (5.8%, n = 21), and Midatlantic (5.3%, n = 19).
On the basis of the average LSR scores, the two factors that had the greatest overall influence on the selection of a specialty fellowship were intellectual stimulation (mean LSR, 3.38 of 4) and the variety of surgical cases (mean LSR, 3.28 of 4). Categorical PGY seniority was associated with substantially different average LSR scores for geographic location (P < 0.001), proportion of outpatient surgery (P = 0.028), ability to practice at a private hospital (P = 0.008), on-call duties (P = 0.009), financial compensation (P < 0.001), and variety of surgical cases (P = 0.042) (Table 3). There was no statistically significant relationship between categorical PGY seniority and import assigned to research or academic pursuits, desire for intellectual stimulation, influence of a mentor, marketability, altruism, tradition, or multidisciplinary care.
Compared with senior trainees, junior trainees assigned greater value to geographic location (P < 0.001), on-call duties (P < 0.001), financial compensation (P < 0.001), and the tradition of a residency program placing trainees in specific specialties (P = 0.029) (Figure 1). Conversely, senior trainees assigned greater value to variety of cases (P = 0.004) and intellectual stimulation (P = 0.033) than did their junior counterparts.
When we considered the influence of 14 factors on the selection of an orthopaedic specialty fellowship, factors such as geographic location, outpatient surgery, private practice, on-call duties, and financial compensation all showed significant variation based on categorical PGY seniority. Collectively, junior trainees valued lifestyle factors (eg, geographic location, on-call duties, financial compensation), whereas senior trainees valued intellectual factors (eg, variety of cases, intellectual stimulation).
This study has several limitations. First, the response rate to our survey was low, although we were unable to calculate a true participation response rate because we were unable to confirm that all orthopaedic surgery trainees nationally received the electronic link that was emailed to ACGME program coordinators. On the basis of our calculation, we obtained responses from approximately 359 of 1,932 (19%) of all potentially eligible ACGME trainees.17 This rate is lower than ideal and introduces an element of selection bias inherent in voluntary surveys. However, we obtained a representative distribution of respondents with regard to PGY seniority, geographic location, and sex. Therefore, we think our results could be extrapolated to a larger group.
Second, this survey provides a static picture of influences based on PGY seniority at the time of the survey, and we cannot conclude whether trainees might change the value they assigned to certain factors as they progress through training. Because a large amount of experiential knowledge is gained during training, we think that temporal variation for the influence of factors is to be expected; the alternative would imply an unimpressionable set of circumstances unique to the year in which training began. The distinction between junior (PGY1 to PGY3) and senior (PGY4+) trainees enabled statistical comparisons between larger groups, although we acknowledge that the variation in trainee preferences over time is likely more progressive in nature. Third, it may be difficult to capture all relevant factors with a 14-question survey, and we concede that there are intangible factors that are individualized and difficult to quantify within a group.
Finally, there are factors related to an inherent selection bias within the group that chose to participate in the study. It is difficult to quantify factors specific to a specialty fellowship, such as intellectual stimulation or case variety, which are considered based on personal interests. We acknowledge that we may have omitted some factors of importance; however, we aimed to keep the survey short to maximize the number of quality respondents, and, after reviewing the relevant literature, we chose 14 questions on the basis of factors we ascertained to be relevant to the young orthopaedic surgeon.
Because subspecialization has increased among orthopaedic surgeons, trainees must prepare themselves adequately for a competitive job market. Morrell et al8 reviewed employment and practice postings listed in the Journal of Bone & Joint Surgery, American Volume and found a progressive increase in job opportunities seeking fellowship-trained orthopaedic surgeons from 16.7% in 1984 to 68.2% in 2009. This trend may reflect growing pressures on healthcare institutions to deliver highly specialized treatments while offering a broad range of services. Also, specialization may allow individual surgeons to perform fewer types of preferred surgeries in greater volumes. It is notable that the trainees in our study assigned the greatest value to variety of cases and intellectual stimulation despite the growing body of knowledge that indicates specialization in performing fewer surgeries at higher volumes is associated with improved patient outcomes.18-21 However, we did not define “variety of cases” in a way that would allow proper distinction between the overall number of different cases versus the particular variety of cases associated with a specific specialty. Thus, the implications of these results may be limited.
In our analysis, we attempted to distinguish between lifestyle factors and intellectual factors because previous investigators have identified these factors to be relevant to residents’ career plans.1,11 Chung et al11 made this distinction in a survey of residents considering the pursuit of a hand surgery fellowship. In their analysis, a 1-point increase in the LSR of intellectual issues was associated with 10 times greater chance of specializing in hand surgery.11 In 2011, Hariri et al1 surveyed senior orthopaedic surgery residents and found that the top priorities they considered when choosing a subspecialty were intellectual (40%), educational (36%), lifestyle (21%), and economic (4%). We had similar findings; intellectual factors were more important than lifestyle factors among senior trainees. However, in contrast with our study, which featured LSRs of 14 categories, the survey by Hariri et al1 asked participants to rank four categories (eg, economic, educational, lifestyle, intellectual) and did not include junior trainees.
The higher value assigned to intellectual factors by senior trainees relative to junior trainees supports the notion that influences encountered during the progressive and cumulative experience of residency training are formative in guiding career choice. One possible explanation for this finding is that trainees initially focus on factors relevant to orthopaedic surgical practices as a general specialty, such as on-call responsibilities, financial compensation, and outpatient care as opposed to more subtle differences among individual subspecialties. As residency progresses, trainees gain a further appreciation for the subtleties that differentiate orthopaedic subspecialties. In addition, because most senior trainees already had decided on a fellowship, we presumed that their responses were reflective in nature, whereas the responses of junior residents may have been prospective in nature.
When selecting a specialty fellowship, senior orthopaedic surgery trainees valued case variety and intellectual stimulation over other factors, whereas junior trainees valued lifestyle factors. This evolution of value assignment may highlight the relative importance of greater exposure to the breadth of orthopaedic surgical practice during training and increasing awareness of clinical competencies and responsibilities, global patient care, and appreciation for longer-term clinical outcomes; these combined experiences are important for career decision making. Additional studies are needed to validate these data and may benefit from an increased response rate through direct contact of eligible trainees, differentiation between fellowship- and non–fellowship-bound trainees, differentiation by anticipated subspecialty of choice, and better delineation of value through ranking as opposed to an LSR system. Our study is important because it highlights the temporal plasticity that exists regarding career values, and it can help guide future studies regarding factors of highest variability and overall value.
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