The international orthopedic surgery fellow: the beginning of the end.

To the Editor: I recently learned that the Accreditation Council for Graduate Medical Education (ACGME) has issued new ACGME Program Requirements for Graduate Medical Education that will go into effect July 1, 2016. The changes pertinent to or-thopedic surgery residencies and fellowships were recently shared and discussed with the corresponding program directors in preparation for their implementation. One major change that will go into effect is the restriction of fellowship positions to graduates of ACGME-accredited residency programs, and Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or The College of Family Physicians of Canada (CFPC)-accredited residency programs located in Canada. 1 Exceptions are allowed and may be granted by the review committee for exceptionally qualified applicants on assessment of the program director and fellowship selection committee and subjected to the approval of the applicant's exceptional qualifications by the graduate medical education committee. Having been on the receiving end of this requirement, I see several disadvantages that may undermine the benefits of restricting fellowship training to ACGME-accredited residents. This restriction may show a negative effect on the following 3 levels: The Applicant. Subspecialty fellowship training is popular among international medical graduates (IMGs)—graduates of non-ACGME orthopedic residency programs by default. There were 445 fellows enrolled in orthopedic surgery sub-specialties in 2012. 2 Many of them return to their countries of origin, while a few stay and practice orthopedics in the United States. International medical graduates who seek entry into US graduate medical education programs must obtain an appropriate visa that permits clinical training activities. One popular visa is the J-1 visa. The Educational Commission for Foreign Medical Graduates (ECFMG) is the official entity authorized by the US Department of State to sponsor J-1 physicians to enroll in accredited programs of graduate medical education. 3 Restricting enrollment in accredited fellowship programs is practically a denial of fellowship training for the vast majority of IMGs. The Fellowship Program. The Table summarizes the or-thopedic residency and fellowship positions filled across the United States in 2012. 2 I sorted the numbers by IMG participation. The Table shows that while IMG residents constituted no more than 2.4% of the total orthopedic resident population, IMG fellows held an average of 13.7% of fellowship positions, and as high as 35.5%. Once the new requirement goes into effect , a few of the fellowship programs may have a difficult time filling their positions. The Physician Work Force. International medical …