Academic journal article Education Research International

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

Academic journal article Education Research International

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

Article excerpt

K. A. Almansoori 1 and M. Clark 2

Academic Editor:Bruce Keith

1, Department of Educational Psychology, University of Alberta, Edmonton, AB, T6G 2G5, Canada
2, Division of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, T2N 4N1, Canada

Received 5 June 2014; Accepted 29 December 2014; 20 January 2015

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Introduction

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 [1]. 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 [1-3]. 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 [1, 4, 5]. Unfortunately, even though orthopedics is shown to have exceedingly high fellowship enrollment rates, very few studies have investigated this phenomenon [1-3, 6-8].

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 [3, 7]. 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 [6, 7, 9, 10]. However, producing an excessive number of subspecialists can lead to a poor distribution of general orthopedic services, particularly in the setting of limited healthcare resources and smaller-community accessibilities [2, 3, 7]. This is especially true when recognizing that over the last two decades, the number of specialist orthopedic surgeons has continued to increase while the number of practicing general orthopaedic surgeons has continuously decreased [6, 7, 11]. Therefore, understanding why residents are increasingly pursuing fellowships is important for the administration of future healthcare services as well as surgical education programs.

Previous studies have identified several factors guiding residents to pursue fellowships and include financial incentives and opportunities related to subspecialization, the medical malpractice environment by which certification may provide greater litigation protection, the preference for fellowship-trained surgeons at many academic institutions, a generally greater awareness among residents of patient outcomes and lifestyle factors, and employment opportunities related to subspecialization [6, 7, 12-15]. Likewise, demographic factors, like the female gender, residents from community-based programs, international medical graduates, and residents with prior graduate degrees (e.g., masters or doctoral degrees), have also been correlated with a greater likelihood of pursuing a fellowship [2, 16, 17]. …

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