AAOS Bulletin - June, 2006

Interest and marketability drive specialties

By Kenneth S. Bode, MD, Capt., MC, FS, USAF

Medical specialties have trended toward subspecialization for a number of reasons, and there are many speculations about why orthopaedic surgeons choose a certain subspecialty field. Approximately 600 individuals complete graduate surgical education in orthopaedic surgery each year in the United States. Their subsequent career pathways have not been described, but may have relevance to the supply of orthopaedic surgeons available to provide a broad range of surgical care.

To explore the surgical attitudes and preferences regarding fellowship training among orthopaedic residents, my colleagues (James R.T. Bales, MD, Charles Haggerty, MD and David Christensen, MD) and I conducted a survey of senior residents. Our goal was to allow graduating residents to voice why they chose a certain path as well as chart trends and benchmark from previous studies.

Surveys were sent to 131 orthopaedic surgery program directors for distribution to senior residents in that program. Surveys were returned by 482 (40 percent) of 1,217 graduating residents (2004/2005). Of these respondents, 80 percent were training at a university-based medical center and 19 percent were at a community hospital; 91 percent were male.

The survey asked residents to rate the importance of ten items, using a Likert scale of 1-10, and how each pertained to their decision of whether to do an immediate post-residency fellowship. Among respondents, 81 percent indicated that they would enter clinical fellowship training immediately after completing their orthopaedic surgery residency. Of the remaining residents, 48 percent planned to attend fellowship training at some point in their career. A previous study had indicated that two-thirds of all orthopaedic residents would be attending fellowship training immediately after graduation.1

Based on our survey, the primary reason that senior residents are going on to postgraduate fellowships is personal interest; 92.5 percent of respondents gave personal interest a scaled score of 8-10 (mean=9.07 1.34). Marketability, inspiration from an attending, income, and encouragement from an attending followed in that order. In contrast, dislike of other subspecialties and having a job guaranteed in a specific subspecialty were the lowest-rated factors.

Among respondents not choosing a post-residency fellowship, reasons included a lack of personal interest in any specific area and a feeling that the residency training/experience was adequate.

Of the respondents, 31 percent desired a sports fellowship; 16 percent had interests in hand/shoulder and 15 percent had interest in spine. A 1998 study reported the same trend. In that study, 20 percent of residents wanted to pursue sports medicine, 12 percent were interested in hand, and 9 percent were going on in spine surgery.1

Our survey also found nearly 9 percent of residents interested in joints, while trauma and foot and ankle each had interest ratings of about 7 percent. The lowest percentages were in pediatrics (4 percent) and tumor (1 percent).

Also of interest in this study were the evaluations of the content and adequacy of orthopaedic surgery residency training. In evaluating a residency program, the Accreditation Council for Graduate Medical Education and the Residency Review Committee set standards for accreditation. Residents’ perception of the content and adequacy of their training is another method of evaluation. Respondents to our survey rated their general orthopaedic training at 8.35 (1.3) out of 10.

A previous study reported a similar trend, with a majority of residents rating their general experience at above average.1

Kenneth S. Bode, MD, is a captain in the United States Air Force and a senior resident at Wilford Hall Medical Center.


1. Dailey SW. Orthopedic residents’ perceptions of the content and adequacy of their residency training. Am J Orthop 1998; 27(8):563-70.

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