Relationship Between Subspecialty Rotation Exposure and Program-specific Factors
Of the 106 programs, 45.3% (n = 48) had 4 to 5 residents/yr, 30.1% (n = 32) had ≥6 residents/yr, and 24.5% (n = 26) had 1 to 3 residents/yr (Figure 4). There were no significant differences in the percentage of residency spent on subspecialty rotations based on program size (1 to 3 residents, mean 62.3%; 4 to 5 residents, mean 63.9%; and ≥6 residents, mean 62.9%; P = 0.80). Programs with subspecialty fellowships at their institution spent an average percentage of time on subspecialty rotations of 63.9% compared with programs without subspecialty fellowships in which 61.4% of time was spent on subspecialty rotations. This difference was not statistically significant (P = 0.77).
The purpose of this study was to summarize the current subspecialty rotation exposure between ACGME-accredited orthopaedic surgery programs. We found that residents on average spent the most time on trauma rotations, followed by general orthopaedics and pediatrics. Subspecialty rotation exposure among programs was highly variably; as such, we found no notable correlations between subspecialty rotation exposure and program size or presence of fellowship training at the corresponding institution. Our study also demonstrated that most programs have dedicated time for research (63.2%) and about a quarter of the programs offer residents dedicated elective time.
Our finding that 63.2% of programs offer dedicated research time is consistent with that of Williams et al.,8 who reported that 69.6% of ACGME-accredited orthopaedic programs offer residents protected research time. This percentage is likely higher than ours because Williams et al.8 included programs with longitudinal research time across the 5 years, which was not represented on the block rotation schedules that we analyzed. Previous literature has not characterized how common it is among orthopaedic programs to offer elective time for residents. In the landscape of increasing competition for orthopaedic fellowships and specialization by practicing orthopaedic surgeons, these trends may increase moving forward.
Dedicated research and elective time provide residents with more autonomy and may help to position them more favorably for fellowship applications. Increased autonomy is also known to increase motivation, which may increase general resident experience and well-being. Protected research time has been associated with an increased number of publications in residency,8 and electives offer residents an opportunity to gain additional experience in research or their subspecialty interests. Our study showed that both research and elective rotations are variable between programs. Program administrators may take these data in to consideration because they modify and enhance their curricula.
This study has several limitations. Our findings are only as strong as was our ability to accurately categorize each rotation listed on the rotation schedule. Several programs' rotation schedules categorized rotations by hospital name instead of the nature of the clinical experience. As a result, we excluded programs in which we were unable to adequately categorize over 3 months of time in the rotation schedule over the course of the 4 years examined. However, for included programs where between 1 and 3 months of time was unable to be categorized, it is possible that the time spent on subspecialty rotations was underestimated, unaccounted for, or inappropriately represented. Another limitation was the heterogeneity in means by which rotation schedules were obtained and reported and the fact that program curriculum may change from year to year. Although sources such as websites may not reflect the most current program practices, a recent study showed that orthopaedic surgery residency program websites have markedly increased in comprehensiveness over the past 10 years.9
We also acknowledge some limitations in appropriate categorization of trauma. Although the ABOS requires a minimum of 12 months, our study found an average of 8 months across programs. This discrepancy may be linked to the fact that trauma is incorporated into many general orthopaedics rotations and as such, residents are exposed to additional trauma on these rotations. The sum of the average number of months spent on general orthopaedics and trauma in our study equals 14.4 (closer to the 12-month ABOS requirement), suggesting that a large overlap exists between general orthopaedics and trauma. Because of this overlap, we decided to exclude the time spent on trauma from the total time spent on subspecialty services in our analyses examining the association between subspecialty rotation exposure and program size/fellowship availability. In support of these methodological decisions, our data closely parallel the ABOS requirement for months spent on pediatric orthopaedics (6.0 months), and this subspecialty rotation also had less variation between programs. This consistency indicates two important points. First, this suggests generalizability of accuracy in our ability to categorize the other subspecialty services, and second, less variation exists in the categories in which the ABOS provides guidelines.
It is important to underscore that the time spent on subspecialty rotations does not equate with resident surgical or educational experience on the rotation. The aim of this study was to provide summative information regarding the amount of time residents are being exposed to different subspecialty rotations between programs where these data are not publicly available from the ACGME. Our study found a relatively smaller variation in exposure to pediatric orthopaedic surgery, likely because that it is the only subspecialty in our analysis for which the ACGME provides guidance to programs regarding resident exposure. To better understand the educational impact of subspecialty rotation exposure, it would be important to study how the amount of time spent on a rotation correlates with the number and type of surgical cases residents performed or performance on standardized tests of knowledge. Unfortunately, although the ACGME provides national average case log data, program-specific information is not publicly available and was therefore not feasible in the present study of 115 residency programs. Furthermore, as demonstrated in Figure 1, ACGME's representation of the case log data does not allow one to understand where the case exposure is coming from for the different rotations.
Finally, there are likely many more factors contributing to the current variation in subspecialty exposure between programs than those measureable in this study, including the specific hospital and patient care environment, teaching faculty, and the available volume and diversity of clinical opportunities between programs.
Our study found a high variability in the subspecialty rotation exposure among ACGME-accredited orthopaedic surgery residency programs. Additional research should be conducted to investigate the impact of this variation on resident experience, competency, and satisfaction. It is important for graduate medical education leadership to understand and appreciate this variation as they consider alternative training structures. Program directors receive data from the ACGME, detailing how their program case volumes compare with national averages. The ACGME does not currently provide summative national program data regarding rotation structure. In combination with available case log data, program directors can use the information presented in this study to compare their rotation structure with other ACGME-accredited programs to inform changes to their curriculum. Furthermore, applicants to orthopaedic surgery residencies may also benefit from knowledge of this variability as they compare programs.
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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons
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