Additional thoughts on orthopedic residency and fellowships.

In the guest editorial “The Education of Orthopedic Residents and Fellows” (http://www.orthosupersite.com/view. aspx?rid=60341) in the February 2010 issue of ORTHOPEDICS, my co-author and I expressed concerns over the perceived impact of the increasing popularity of fellowships on residency programs, while making suggestions on how to prevent harmful, unintended consequences. In that article, we attempted to study the genesis of fellowships, and particularly their rapid spread. We speculated that the initial interest in them was the residents’ desire to overcome perceived defi ciencies in specifi c areas of the discipline that may have resulted from the proliferation of subspecialties services that brought about a shortening in the length of rotations over the 5 years of structured education.1 I had long suspected that such an explanation was not necessarily accurate, since within a short time most residents pursuing an additional year of fellowship were not choosing training in areas of perceived defi ciencies but in areas where greater opportunities for lucrative practices were more likely to exist. The rapid growth in interest in fellowships, however, came with obstacles for many since saturation with newly graduated fellowship-trained orthopedists wishing to limit their practice to the subspecialty of their fellowships is already taking place in many cities. The number of super-specialized orthopedists that a given community can afford to have is based on the size of the population in the area to be served. A city of any size may provide an adequate number of patients to satisfy the emotional, professional, and fi nancial needs of only a certain number of such specialized surgeons. If their numbers exceed those criteria, they begin either to increase the indications for surgery (which has a limit) or to broaden the scope of their practices into areas where they had previously felt insuffi ciently trained to perform well. As the number of fellows in orthopedic programs affi liated with medical schools has increased exponentially in recent years,