We compared time allocated for various subspecialty rotations with the subspecialty of residency director and department chair. One hundred ten program sites had information about the chair's subspecialty, and 114 programs had information about the residency director's subspecialty.
If the PD was a generalist, residents tended to spend more time on general orthopaedics (22 versus 9.9 months, P = 0.001). There was also a slightly increased time spent on orthopaedic oncology if the PD was an orthopaedic oncologist (3.8 versus 3.00 months, P = 0.011) and if both the PD and the chairman were orthopaedic oncologists (3.5 versus 2.7 months, P = 0.010).
Programs often send their residents to gain experience in certain subspecialties to off-site locations that may not be directly available at their primary teaching institution. One hundred seven program sites gave information on outsourced subspecialties in foot and ankle, 108 for general, 119 for hand, 113 for adult reconstruction, 99 for oncology, 121 for pediatrics, 118 for spine, 117 for sports, and 118 for trauma. For adult reconstruction, programs that sent their residents to another institution for their arthroplasty experience spent more time on the adult reconstruction rotation than those that stayed at their home program (7.1 versus 5.6 months, P = 0.031). Furthermore, residents at programs with a hand fellowship at the home program spent more time on hand rotation than those without a hand fellowship (5 versus 4.2 months, P = 0.012).
Time spent on various subspecialty rotations based on different US geographic regions is summarized in Figure 3. Three subspecialties (foot and ankle, orthopaedic oncology, and trauma) demonstrated statistically significant variability in the time allotted based on geographic regional variation. In foot and ankle, programs in the South and Midwest spent 3.4 and 3.5 months, respectively, compared with 2.8 and 2.9 months, respectively, for Northeast and West (P = 0.03). In orthopaedic oncology, programs in the South and West spent 3.2 and 3.3 months, respectively, compared with 2.5 in Northeast and Midwest (P = 0.04). Finally, in trauma, programs in the South and West spent 9.4 and 10.6 months, respectively, compared with 7.5 and 8.9 months, respectively, in the Northeast and Midwest (P = 0.03). Based on multiple linear regression analysis, time allotted for adult reconstruction (t = 2.29, P = 0.02) and elective rotations (t = 2.43, P = 0.017) was positively associated with the number of residents in the program.
We studied the variability of time allotted for various clinical rotations across the 151 orthopaedic residency programs in the United States. We found that community programs tended to spend more time on adult reconstruction. Increased numbers of female residents correlated with more time spent on elective and pediatrics and with less time spent on hand rotation. Larger program size correlated with more time spent on elective rotations and that university programs tended to have larger programs. Programs with chairs who were generalists or orthopaedic oncologists tended to have more time allotted to those specialties, respectively. Programs with hand fellowships tended to spend more time on hand rotations. Geographically, programs in the South and Midwest spent more time on foot and ankle, whereas programs in the West and South spent more time on oncology and trauma rotations.
University-based Versus Community Programs and Outsourcing
Our data demonstrated that residents in community programs on an average spent more than a month longer on adult reconstruction service compared with university-based programs. This phenomenon may reflect the distinctive patient and clinical faculty demographics seen at university-based versus community programs and different perceived needs of training between the two settings. Overall, more arthroplasty procedures are performed at community hospitals compared with university-based centers.8 This discrepancy may be related to the fact that medical care, including arthroplasty, is more costly at academic centers compared with community centers to account for teaching costs and overall overhead.9–11 This phenomenon likely contributes to residents in community-based programs spending more time on arthroplasty/reconstruction rotations as noted in our study. Interestingly, residents who had an off-site location for adult reconstruction training also spent more time doing adult reconstruction. One possible explanation for this finding may be that residents are specifically sent to high-volume arthroplasty centers and thus gain a more focused adult reconstruction experience.
In addition, as seen in the comparison with the 2018 OITE breakdown, the time spent on a clinical rotation is roughly correlated with the number of questions for the given subspecialty. This finding suggests that clinical rotations are fairly well distributed compared with the weightage of questions on the In-Training Examination.
Orthopaedics remains one of the least diverse medical specialties with only about 13.1% of orthopaedic residents being women.12,13 This phenomenon is particularly interesting, given the fact that medical matriculates are now nearly evenly split between the two sexes.14 Although there may be multiple reasons for this finding, given the context of our study, we noted a positive correlation between the number of female residents in the program and the amount of time allocated to elective rotations and pediatric orthopaedics. Although it is unclear whether female candidates have a propensity toward programs with more pediatric experience, it is interesting to note that in the 2016 to 2017 academic year, pediatric orthopaedic fellowships had the highest proportion of female matriculates.15 Although we were unable to establish causality, a survey of orthopaedic residents conducted by Hariri et al16 noted that a higher percentage of women planned to pursue pediatric orthopaedic fellowship compared with men (24% versus 6%). Perhaps prospective female residents may find programs that focus on pediatrics more appealing and may have more female role models in that field. On the other hand, we noted a negative correlation between the number of female residents in a program and the time allocated to hand rotation. According to Chung et al,17 significant factors that influence resident selection of hand surgery as a subspecialty are interest in the topic and time exposed to hand rotations. Our study design did not allow us to gain further insight into this topic.
We found that larger programs tended to have more time allocated to elective rotations. This finding could be a reflection of having more resident workforce to distribute the clinical load among residents or an increased resident advocacy as it allows time for residents to explore different academic or service interests. In addition, we found that university-based programs had a higher average number of residents, 23.6 compared with 14.7 across community programs. The Accreditation Council for Graduate Medical Education (ACGME), the governing body of graduate medical education, determines the amount of residents based on program resources—research and educational—and volume.18 Large academic institutions likely have more ability to accommodate these requirements and thus are allotted more residents. Given the possibility of enhancing resident training, it would be beneficial to understand the effect of elective time on resident education and patient care. A previous study of urology resident education noted that elective time in residency curriculum had a positive effect on the program with increased In-Training Examination scores and resident evaluation of the program without detracting from surgical training, having actually found an increase in graduating senior case log numbers.19
The residency PD and department chair can influence the educational curriculum and clinical training received by the residents.20 We noted that having a generalist or orthopaedic oncologist as the PD correlated with more time spent on those clinical rotations. Although it is difficult to say whether the specialty of the department chair/PD directly leads to residents spending more time on those rotations, our results suggest that these leadership positions may influence the educational curriculum of the program. It is interesting to note that in the field of orthopaedic oncology, which is one of the smallest of the orthopaedic subspecialties, simply having an oncology practice as part of a residency program may increase the experience of residents in musculoskeletal oncology.21
Fellowship Offered at Home Program
To have a fellowship, a training program must have a high enough case load, in addition to other academic criteria in that subspecialty.22 We found that residents in programs that had a hand fellowship in-house were allocated more time on the hand service. Having a fellowship in a particular field likely increases the focus in this subspecialty, which coupled with high case load may allow residents to spend more time in that particular field.
Geographic location of the orthopaedic residency may also influence the type of musculoskeletal conditions and diseases seen by the trainees. We found significant correlations between the program location and the amount of time spent on three subspecialties: foot/ankle, oncology, and trauma.
In the field of foot and ankle, the South and Midwest regions spent more time on foot and ankle rotations. Programs in the West and South spent more months on orthopaedic oncology and on trauma rotations. These differences likely represent variability in orthopaedic pathology by geographical region and differences in regional distribution of orthopaedic subspecialists. One aspect that the regional study does not account for is the local community socioeconomic and makeup of the patient population that the residents encounter and the urban versus suburban versus rural location of the teaching institution. For example, an urban teaching institution that is also a level 1 trauma center will likely receive a high volume of traumatic injuries and will likely be associated with an increased trauma experience for the residents. Another aspect, which may contribute to the discrepancy between the time spent on trauma in the West and Northeast, is the density of trauma programs. According to the Orthopaedic Trauma Association, there are 8 trauma programs in the Northeast compared with 11 in the West region.23 In addition, of the 10 Musculoskeletal Tumor Society–recognized fellowship programs, 7/10 fellowship programs as of 2017 exist in the South or West.24 This suggests that time spent on the trauma and oncology services during residency may be higher in and around areas with higher density of such referral centers.
In addition, distribution of medical comorbidities that confound orthopaedic conditions may play a role in the variability of resident clinical exposure. For example, diabetes and obesity have particularly high prevalence in the Midwest and South, according to the Centers for Disease Control.25,26 These comorbidities are known risk factors for certain foot and ankle disorders27 and may increase the prevalence of foot and ankle pathology that requires a fellowship-trained foot and ankle specialist. Interestingly, of the 48 foot and ankle fellowships in the United States, 25 are in the South or Midwest.28 In a study looking at factors influencing fellowship selection by orthopaedic residents, in foot and ankle, practice location was the number one factor and fourth most important factor across all specialties.29 Furthermore, in a study by Vitale et al30 studying shoulder procedures, the authors noted as much as a 10-fold difference in the number of total shoulder versus humeral head arthroplasties versus rotator cuff repairs done based on geographic regions. They found significant association between specific shoulder procedures and the population density, but not to the density of orthopaedic subspecialists.
Our data were collected from publicly available websites of US orthopaedic residency programs; these data may be inaccurate or out of date. Literal interpretation of the named rotations overlooks the nuances that a particular residency's rotation may contain. For example, a general rotation at a community hospital may include both adult reconstruction and trauma under the same designation. In addition, rotation length, while used as a surrogate of case volume, may not accurately reflect the number of surgical cases that involved active participation by individual residents. Although we did note some trends and associations between time allocated to certain rotations and program demographics, these findings were primarily based on univariate analysis of online data. A more personalized inquiry, including review of resident case logs from each program, would be required to validate our findings.
The delivery of health care in the United States is evolving rapidly and will likely affect the postgraduate medical education and training. It is important for programs to plan their curricula to optimize resident learning.31,32 We found some interesting correlations between an orthopaedic residency program's demographic profile and the amount of time allocated to certain clinical rotations during training. Given the paucity of information on this subject, we have provided an introductory foray into some of the demographic factors that may be associated with the length of clinical rotations in orthopaedic residency program across the United States. We hope that our findings can serve as a benchmark to gain further insight into this important topic and can aid educational leaders and other stakeholders of individual training programs to reflect on their educational curriculum.
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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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