Increasing Trends in Orthopedic Fellowships Are Not due to Inadequate Residency Training


Orthopedic residents have one of the highest fellowship participation rates among medical specialities and there are growing concerns that inadequate residency training may be contributing to this trend. Therefore, a mixed-exploratory research survey was distributed to all 148 graduating Canadian orthopedic residents to investigate their perceptions and attitudes for pursuing fellowships. A response rate of 33% () was obtained with the majority of residents undertaking one (27%) or two (60%) fellowships. Surgical-skill development was reported as the most common motivating factor, followed by employment and marketability; malpractice protection and financial reasons were the least relevant. 

The current structure of residency training is based on the framework established by William Halsted in the 1800s by which a new medical-school graduate undergoes a series of apprenticeships under different surgeons to acquire the knowledge and skills necessary for independent practice. Upon graduating from a residency program, a graduate can either begin independent general practice or pursue additional 1-2 years of subspecialization training known as a fellowship. This optional training period first became popular in the 1970s and, since that time, the number of residents pursuing fellowships has dramatically increased across all medical specialities. Currently, fellowship participation rates vary by surgical subspeciality with approximately 70–75% of general surgery and urology residents pursuing fellowships, compared to over 90% of orthopedic residents. Unfortunately, even though orthopedics is shown to have exceedingly high fellowship enrollment rates, very few studies have investigated this phenomenon.

As residents increasingly undertake fellowships, their decisions have strong implications to future healthcare workforce planning and graduate surgical education. There are strong concerns that as more residents enroll in fellowship programs, the educational value of residency training may become undermined: Fellowships may simply represent a “de facto” extension of residency training into a 6-year undertaking, with fellows performing more resident-level duties and residents themselves being suboptimally trained with the mindset that any skill deficits can be learned later during their fellowship period. Of course, having more fellowship-trained specialists is appealing when considering that certain surgical procedures have better productivity and clinical outcomes when performed by a fellowship-trained surgeon. 

The decision to pursue a fellowship is complex and multifactorial, but it has important implications to healthcare workforce planning and the future design and organization of graduate medical education programs. Training surgical residents for independent practice has become increasingly challenging due to the growing volume of administrative and nonsurgical academic activities that residents are expected to perform within a more stringent work-hour time period. Considering these obstacles, we assumed that the primary reason why Canadian orthopedic residents were increasingly pursuing fellowships was due to inadequate residency training. The survey results fail to validate this assertion and, instead, suggest that a resident’s desire to develop and improve their surgical skills is the primary reason for the increasing fellowship trends. In fact, residents generally reported that neither the offer of employment nor changes to the duration or organization of their residency training would dissuade them from pursuing fellowships. These findings highlight a likely misinterpretation between a resident’s need for additional training due to poor residency training (i.e., inadequate-training) and their desire for specialized training in order to master surgical techniques not available at their home institutions (i.e., expert-training). Overall, the survey responses provide preliminary evidence to illustrate that the growing trend in fellowships among Canadian residents is not due to inadequate surgical training, but a combination of more personal and occupational factors which require further investigation.

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