Best Practices for the Spine Fellowship Match: Interview Statistics, Applicant Perspectives, What Programs Look for in Fellowship Applicants, and Guidance

Orthopedic fellowships first became popular in the 1970s.¹ In recent decades, the number of residents pursuing postresidency fellowship training has increased, leading to further specialization within the field.^2,3 Aside from increased clinical knowledge and surgical skill development, fellowship training has been shown to increase employment prospects and compensation for orthopedic surgeons.^4,5

The modern orthopedic fellowship match was established in 2008 to provide a fairer and more organized process for matching residents to fellowship.^6,7 Since then, studies have attempted to quantify the factors that affect the application process, determine how residents establish a rank list, and elucidate the time and financial impact of the fellowship match process.^7–9 Although informative, these studies provide little or no information specific to the spine surgery fellowship match and its applicants. The spine fellowship match is unique because it includes both orthopedic and neurosurgical residents. Moreover, trends and behaviors may change over time.

Here, we identified factors considered most important by spine fellowship applicants when evaluating fellowship programs and provided benchmark cost and application statistics for the spine fellowship match. We also present the best practices in terms of characterizing what programs consider important when evaluating applicants and what applicants should consider when constructing their rank lists.

Interview Statistics and Applicant Perspectives

With the support of the North American Spine Society, an anonymous, nine-item, web-based survey (Alphabet Inc., Mountain View, CA) was distributed to participants in the 2021 and 2022 spine fellowship match. The survey was sent via email approximately one month after match day. This survey was determined to be exempt from Institutional Review Board oversight (HCA Healthcare, 2021-505). All participants provided informed consent.

Applicants were asked whether they matched their specialty (orthopedic surgery or neurosurgery), the number of programs to which they applied, the number of interview offers received, the number of interviews attended, reasons for declining interview offers, percentage of interviews conducted online, and total cost of the spine fellowship application process.

Spine fellowship applicants were also asked to rank the following factors in order of importance to their application decisions: Accreditation Council for Graduate Medical Education (ACGME) accreditation, autonomy, exposure to minimally invasive surgery, exposure to navigation/robotics, exposure to spine trauma, exposure to spine tumor surgery, geographic location, job placement of past fellows, program prestige, program size, reputation of staff/faculty, salary, satisfaction of past fellows, and variety and complexity of surgical exposure. Variables were ranked in order of importance from one to 14. Fifty-two of the survey respondents fully ranked the variables, and the analysis of ranked variables was restricted to complete responses.

A total of 75 spine fellowship applicants completed the survey for a final response rate of 30.12% (75/249). All responders successfully matched into a fellowship. Of the 75 respondents, 74 specialized in orthopedic surgery and one specialized in neurosurgery. Most fellowship applicants (61.30%) applied to >25 programs, with the majority (89.30%) applying to at least 16 programs (Figure 1).

Figure 1: The distribution of the number of programs applied. The majority of applicants applied to >25 programs.

Although 61.30% of fellowship applicants applied to >25 programs, only 16.00% of applicants reported receiving >25 interview offers. Most applicants received 11 to 20 interview offers, with 21.30% receiving 11 to 15 and 36% receiving 16 to 20 interview offers (Figure 2).

Figure 2: The distribution of the number of interview offers received. The majority of applicants received 11 to 20 interview offers.

The number of interviews attended was similar to the number of interviews offered—29.30% of fellowship applicants attended 11 to 15 interviews, whereas 36% attended 16 to 20 interviews (Figure 3).

Figure 3: The distribution of number of interviews attended. The majority of applicants attended 11 to 20 interviews.

Only 32.00% of applicants attended all the interviews they were offered. Comparatively, 68.00% of applicants declined an interview offer, with the most common reason being overlapping dates with other interviews. Most applicants (72.00%) spent ≤$2000 on the application process (Figure 4). This may be reflective of the fact that these data were developed during the COVID-19 pandemic, when most interviews were conducted virtually and, therefore, limited expenses associated with travel including airfare and hotel stays. A prior study evaluating orthopedic residency applicants found a cost savings of $5000 during the pandemic.¹⁰ In our survey, 48% of the applicants reported that all of their interviews were completed virtually, thus eliminating travel costs. Prior studies have reported higher costs for the fellowship application process ($4000–$6000 on average), with some advocating for changes to the process because of the cost burden.^8,9 We found that 68.00% of applicants declined an interview offer, with the most common reason being overlapping dates with other interviews. A previous study demonstrated that 90.5% of applicants declined at least one interview because of conflicting dates.⁹ Prior studies also showed a lower number of applications and interviews attended than that reported here.^8,9 Again, this seems to be an observation reflective of the impact of the COVID-19 pandemic on recent application cycles.

Figure 4: The distribution of the cost of the application process. The majority of applicants reported spending ≤$2000 on the application process.

Applicants ranked variables in order of importance to their application process (Figure 5). The variety and complexity of surgical exposure were ranked most important (2.67±2.20, range 1–11), followed by reputation of faculty (3.42±2.13, range 1–9) and autonomy (3.98±2.78, range 1–11). Salary (12.06±2.32, range 6–14) and ACGME accreditation (12.21±2.16, range 5–14) were ranked least important.

Figure 5: Variables were ranked in order of importance to spine fellowship applicants. The mean±SD in ranking is displayed for each variable. Variety of complexity of surgical exposure, reputation of staff faculty, and autonomy obtained the highest mean rankings. ACGME accreditation and salary obtained the lowest mean rankings.

Oser et al⁹ found comparable results in a similar work evaluating sports medicine fellowship applicants. In their analysis, the variety and complexity of surgery exposure, autonomy, and reputation of faculty were found to be the most important factors when selecting a sports medicine fellowship. Spine fellowship applicants value faculty reputation over program prestige, a finding also seen in the work of Oser et al.⁹ Salary and ACGME accreditation were ranked as least important to spine fellowship applicants. The sports medicine fellowship applicants in the work of Oser et al indicated that geographic location, job placement of past fellows, and program size were least important.⁹

A 2015 study by Niesen et al⁷ queried senior orthopedic residents in an effort to quantify the factors that affect the application process and that determine how the applicants establish a fellowship rank list. This study was limited by a ~11% response rate and was predominantly answered by individuals who did not apply to a spine fellowship (88%). Nevertheless, their findings are still informative. Applicants across all orthopedic specialties felt surgical experience, autonomy, and faculty to be the most important factors when choosing a fellowship. Research resources and salary were ranked lowest. As in the work of Oser et al⁹ and our survey, applicants valued faculty composition over the perceptions of program prestige.

What Programs Look for in Fellowship Applicants

In the 2022 spine fellowship match, there were 70 participating programs, offering 138 positions. The overwhelming majority were filled, with just ~5% remaining vacant after the match.¹¹ In 2022, 38% of all orthopedic fellowship applicants attained their first choice for training.¹¹ Therefore, it would seem that the fellowship vetting process, on the part of applicants and programs, is an exercise intended to distill the right fit for both parties as opposed to a high-stakes endeavor where there are winners and losers. That said, there are certain aspects that are important for applicants to understand as they craft their application. In particular, it is vital to be aware of factors that may be more heavily emphasized by fellowship programs, especially those that are more competitive in terms of the number of candidate applications.

In an informal survey of five spine surgery thought leaders from highly recognized spine fellowship programs, several qualities—some mutable and others less so—were highlighted as being highly sought after in fellowship applicants. In terms of selecting for an interview, one of the most influential factors identified by this group was a compelling letter of support from an established spine surgeon in the field, with an outstanding reputation and track record for identifying future talent. Other metrics, including performance on standardized tests and medical school grades were also emphasized.

In terms of ranking for the match, the quality of written letters and support from the applicants’ mentors and spine surgeons at their current program was considered incredibly important. At some fellowship programs, “academic accomplishment” as identified by original research presentations at national meetings and first-author publications play a major role in selecting fellow applicants for interview and ranking for the match. Beyond this, excellent interview skills and a high “emotional intelligence quotient” were prioritized. Experiences working in teams, or stressful situations, such as in the military or competitive athletics, were other factors that were perceived to be valued by programs. In addition, personal statements, letters, and interview-day experiences that conveyed an individual’s personal grit, trustworthiness, honesty, commitment, and work ethic were important factors in how programs ranked their applicants for fellowship training. Ultimately, however, despite the ways that cultural fit can serve as organizational gatekeeping, the general sense of how an applicant would fit into the program’s established culture was featured as a capstone determinant regarding placement on the final rank list.

Guidance for Applicants When Compiling a Rank List

Although there are numerous opinions regarding the most reputable fellowship programs,¹² ultimately, each rank list must be individualized to the applicants’ own particular needs and aspirations. A general best practice is to rank as many programs as one is conceivably willing to attend for fellowship. However, applicants should not rank programs where they absolutely would not want to train, as the fellowship match represents a contractual obligation. Although exemptions are possible in select circumstances, these are exceedingly rare and must be granted after a formal application and deliberation of the Fellowship Match Committee sponsored by the North American Spine Society, Cervical Spine Research Society, and Scoliosis Research Society. Therefore, the optimal approach is for applicants to only rank those programs where they are willing to engage in fellowship training.

Beyond the facets of fellowship training already outlined, applicants should consider the type and extent of training offered, location, social support network and how these factors dovetail with career aspirations and near-term and long-term goals for clinical practice. A basic strategy is to compose a list of all rankable programs and outline the pros and cons of each, distilled through the individual applicants’ perceived needs and expectations for their fellowship experience. The provisional list can be shared with family, friends, and mentors for minor adjustment. Input from other individuals who recently have gone through the match process, or just finished fellowship training themselves, can provide additional insight and perspectives. Ultimately, the final list should represent a tiered structure of programs that meet the needs of the aspiring spine fellow with respect to clinical development, education, and career support over the year of training, as well as in the long term.

Conclusions

Here, we have identified factors considered most important by spine fellowship applicants and have provided benchmark cost and application statistics for the spine fellowship match. We have also outlined what many programs consider important when evaluating applicants and what applicants should consider when vetting programs for their final rank lists. When evaluating programs, recent spine fellowship applicants seem to value variety and complexity of surgical exposure, reputation of faculty, and autonomy the most. Applicants value faculty over perceived program prestige. Salary and ACGME accreditation were considered the least important. In 2021 and 2022, the majority of spine fellowship applicants applied to over 25 programs, attended 11 to 20 interviews, and spent <$2000 on the application process. These findings should be interpreted with caution as they were undoubtedly impacted by the COVID-19 pandemic and the heavy reliance on virtual interviews over this time period. In terms of programs ranking applicants, the quality of written letters and support from the applicants’ mentors and spine surgeons at their current program are considered of vital importance as are interview skills, academic performance, prior experience, and perceptions regarding how applicants mesh with a fellowship’s established culture. When ranking their preferred programs, applicants should consider the type and extent of training offered, program reputation, faculty composition, location, social support network, and how these factors dovetail with career aspirations and near-term and long-term goals for their own clinical practice post-fellowship. We hope that the information presented here will prove informative to aspiring spine surgeons as they negotiate the spine fellowship match.