Orthopedic Residency Guide-2014

Orthopedic
Residency Guide
Orthopedic
Residency Guide
Editors
Sean E Mazloom MD
Resident, Department of Orthopedics
University Hospitals
Case Western Reserve Medical Center
Cleveland, Ohio, USA
Javad Parvizi MD FRCS

Professor, Department of Orthopedic Surgery
Jefferson Medical College, Thomas Jefferson University
Vice Chairman of Research
Rothman Institute
Philadelphia, Pennsylvania, USA
Foreword
James J Purtill MD
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Orthopedic Residency Guide

First Edition: 2014
ISBN 978-93-5152-094-8
Printed at:
Dedication
I want to dedicate this book to my wife and best friend, Golta, for
her unconditional and beyond imagination love and support.
From the day we met, you have brought true happiness and
laughter to my life. You taught me to be free and most importantly
you showed me how to appreciate the beauty of small things in life.
I also would like to thank our parents for all the sacrifices they
have made for us and
to all of those who have taught me how to be a better person.
—Sean E Mazloom
I want to dedicate this book to residents in orthopedics for their

devotion, enthusiasm, and perseverance.
— Javad Parvizi
Contributors
Kasra Ahmadinia MD Major Melvin Helgeson MD

Spine Fellow Medical Student and Intern
Rush Medical College Coordinator, Orthopedic Spine
Chicago, Illinois, USA Surgeon, Walter Reed National
Military Medical Center
Antonia F Chen MD MBA Bethesda, Maryland, USA
Resident, Department of
Stephanie Krema MD
Orthopedic Surgery
Senior Resident, Department of
University of Pittsburgh
Emergency Medicine
Pittsburgh, Pennsylvania, USA
University of Louisville
Louisville, Kentucky, USA
Captain John P Cody MD
Senior Resident, Department of
Jonathan B Macknin MD
Orthopedic Surgery
Walter Reed National Military
Orthopedics
Medical Center
University Hospitals, Case
Bethesda, Maryland, USA Western Reserve University
Major Jonathan F Dickens MD
Fellow, John A Feagin Jr Sports Sean E Mazloom MD
Medicine Fellowship Resident
United States Military Academy Department of Orthopedics
West Point, New York, USA University Hospitals, Case
Western Reserve Medical Center
Christina J Gutowski MD MPH Cleveland, Ohio, USA
Resident
Department of Orthopedic Troy Mounts MD
Surgery Chief Resident
Thomas Jefferson University Department of Orthopedics
Hospital Case Western Reserve University
Philadelphia, Pennsylvania, USA Cleveland, Ohio, USA
viii Orthopedic Residency Guide
Javad Parvizi MD FRCS Jonathan Streit MD

Professor, Department of Resident
Orthopedic Surgery Department of Orthopedics
Jefferson Medical College University Hospitals
Thomas Jefferson University Case Medical Center
Vice Chairman of Research Cleveland, Ohio, USA
Rothman Institute
Philadelphia, Pennsylvania, USA Sean A Tabaie MD
Resident
Marie-France Rancourt MD Department of Orthopedic
PGY-4, Department of
Surgery
Orthopedic Surgery
Saint Louis University
University of Ottawa
St Louis, Missouri, USA
Ottawa, Ontario, Canada
Andrew Tsai MD
Golta Rasouli MD
Resident
Neurology, Case Western Department of Orthopedics
Reserve University University Hospitals
Cleveland, Ohio, USA Case Medical Center
Colonel Scott B Shawen MD
Residency Program Director Eugene Y Tsai MD
Director, Foot and Ankle Surgery Resident
Walter Reed National Military University Hospitals
Medical Center Case Western Reserve University
Bethesda, Maryland, USA Cleveland, Ohio, USA
Foreword
Applying for orthopedic surgery residency training is very compe-

titive. There are many more applicants than training spots available.
High job satisfaction for orthopedic surgeons, excellent remuneration,
high patient treatment success rates, and good quality of life combine
as driving forces to keep interest in this specialty keen. Applicants
to orthopedic surgery residency are among the very best and most
accomplished of graduating American medical students. In addition
to outstanding grades, orthopedic surgery residency applicants have
shown an escalation of USMLE scores and a proliferation of research.
The process for choosing orthopedic residents is complex.
Medical students apply during the fourth year of medical school.
Residency programs screen candidates, review some applications
in depth, and interview candidates. Letters of recommendation,
Dean’s letters, and personal statements are read. Medical students
often complete subinternship “audition rotations” in orthopedic
surgery. Medical students participate in orthopedic research projects.
There are occasional faculty phone calls on behalf of candidates,
and existing residents are polled for their opinion. What emerges
is a picture of the applicant that is employed by residency selection
committees to rank candidates.
The depth and breadth of exposure to orthopedic surgery during
medical school are varied. Not all medical schools require students
to spend time on an orthopedic rotation. Many medical students
have little opportunity for participation in orthopedic research.
High-profile academic orthopedic surgeons are concentrated in only
a few academic centers. Given these issues, some orthopedic surgery
applicants may find challenges in producing an application that grabs
attention with a robust academic profile.
Orthopedic department oversight from university adminis-
trations, the Accreditation Council for Graduate Medical Educa
tion (ACGME), the federal government as well as various non-
governmental organizations has increased. Restrictions on resident
x Orthopedic Residency Guide
work hourshave tightened. Case logs, milestone reporting, and

surgical simulation skills training requirements have all been insti
tuted in the last decade. Challenges such as these have increased the
complexity of training orthopedic residents but offer the promise of
making them better educated and prepared for practice.
Drs Mazloom and Parvizi have produced a book that highlights
the important steps in the process from developing an interest in a
career in orthopedic surgery to securing a position in orthopedic
surgical training. The complete spectrum of issues are addressed and,
taken as a whole, this work provides a formula for successful pursuit
of this most rewarding medical specialty.
James J Purtill MD
Assistant Professor
Department of Orthopedic Surgery
Jefferson Medical College
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Preface
Orthopedic surgery continues to be one of the most sought after and

popular surgical disciplines today. There is a multitude of reasons
for the popularity of our discipline. Ability to “cure” patients of
their condition, continued exciting advancements in the field and
growth of the specialty, availability of variety of surgical procedures,
dedication of the orthopedic surgeons to their discipline, and the fun
loving nature of orthopedic surgeons are some of the reasons why
medical school graduates seek orthopedics.
Because of this rising popularity, entry to orthopedic surgery has
become very challenging in recent years. The quality of candidates
applying to orthopedic has become ever more impressive. This book
is written with the intention of outlining the strategies that candidates
may employ in their mission to match into orthopedic surgery.
The chapters are written by experts who have provided practical
suggestions to candidates from all walks of life. We are certain
candidates seeking admission to orthopedic surgery will find this
book useful.

Sean E Mazloom
Javad Parvizi
Acknowledgments
I would like to express my sincere gratitude to many great individuals

who helped us in writing this book. Without all your support, remarks
and comments, we would not be able to have this book today.
Above all, I want to thank my wife, Golta, who has always inspired
and encouraged me to achieve my goals in spite of all the time they
have taken me away from her. I would also like to thank my entire
family for their endless love throughout my life. An honorable
mention goes to a great friend and mentor, Cyrus Rasouli, for all his
support, guidance and encouragement in the past several years.
I would also like to greatly thank our editor and publisher M/s
Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India, for
their continuous work and commitment to this project.
Last but not least, words are inadequate in offering my special
thanks and gratitude to all the hard working residents and physician-
scientists who continue to dedicate their lives to medicine and to
caring for others.
Sean E Mazloom
Contents
Introduction xix
Sean E Mazloom, Javad Parvizi
1. The History of Orthopedics 1
Jonathan B Macknin
2. First and Second Year of Medical School 9
Golta Rasouli, Sean E Mazloom, Stephanie Krema
• Mastering and Acing the Basic Science Courses 10
• Second Year of Medical School and Usmle
Preparation 13
• Usmle Review Books and Preparation Courses 15
• Usmle Practice Questions 16
• Scheduling Your Step 1 Examination 16
• Alpha Omega Alpha Honor Medical Society 17
• Extracurricular and Social Activities 18
• Organizations and Clubs 18
• Shadowing Physicians 19
3. Keys to Success in the Third Year of
Medical School 21
Sean E Mazloom, Eugene Y Tsai
• Clinical Rotations 21
• Keys to Success during Your Clinical
Rotations 24
• Third-Year Orthopedic Surgery Electives 30
• Research Involvement 30
• Application to Residency Programs 30
• Usmle Step 2 Clinical Knowledge and Clinical Skills
Examinations 31
xvi Orthopedic Residency Guide
4. Away Rotations and Electives 33

Sean A Tabaie, Sean E Mazloom, Andrew Tsai
• Objectives of Away Rotations and Electives 33
• Home vs Away Electives 34
• When to Schedule the Electives 35
• Benefits of Away Rotations 37
• Where to do Away Rotations 39
• When to do Away Rotations 41
• How Many Away Rotations? 42
• Letters of Recommendation 43
• Where to Stay 44
5. The Application Process 49
Sean E Mazloom
• Undergraduate Years 49
• Electronic Residency Application Service 52
• Personal Statements 54
• Letters of Recommendations (Lors) 55
• Residency Applicants Timeline: Eras 2014 56
6. Interviews and Preparations 59
Sean E Mazloom, Troy Mounts
• How Many Interviews to Go to? 61
• Booking Your Flights and Hotels 62
• Interview Preparation 62
• Social Events 64
• The Interview Day 65
• Interviews 66
• Staying in Touch after the Interview 67
7. Orthopedic Programs and the Ranking Process 71
Sean E Mazloom, Andrew Tsai
• The Nrmp Match 71
• Factors to Consider in Ranking the Programs 72
Contents xvii
• Academic Versus Community Orthopedic
Programs 74
• Match Results Information 77
• Examples of Violations 80
8. What If You Do Not Match? 83
Sean E Mazloom
• Soap 84
9. Research: Before and During Residency 91
Sean E Mazloom, Jonathan Streit
• Taking an Year off during or after Medical School for
Research 92
• Types of Research 93
• Research during Residency 96
10. Women and Minority Students Interested in
Orthopedic Surgery 103
Christina J Gutowski
• Statistics 105
• Strategy for the Residency Application Process 108
• Challenges during Residency 121
• Achieving Success during Residency 124
11. Success during Orthopedic Surgery Residency 129

Kasra Ahmadinia
• Intern Year 129

• Junior Year 132
• Senior-Level Resident 136
• Special Topics during Residency 139
• Fellowship Planning 141
• Research 142
• Conferences and Skills Lab during Residency 144
xviii Orthopedic Residency Guide
12. Orthopedic Fellowship Application Process 147

Antonia F Chen
• Choosing Where to Apply 149
• Application Process 154
• Selection Criteria 157
• Interviews 160
• Rank List 162
• Matching Process 163
13. Orthopedic Residency in Canada 165
Marie-France Rancourt
• Application 166
• Interviews 171
• Deciding on a Residency 172
• Ranking and Matching 174
• Second Iteration 175
• Residency Life in Canada 176
14. Military Candidates and the Secrets to a
Successful Match in Orthopedic Surgery
Residency and Fellowship 179
Major Jonathan F Dickens, Captain John P Cody,
Major Melvin Helgeson, Colonel Scott B Shawen
• History 179
• Military Pay and Incentives 180
• Military Service 181
• Military Orthopedic Residency Programs 184
• Application and Selection Process 191
• Fellowships 196
Index 199
Introduction
Sean E Mazloom, Javad Parvizi
In the last few decades, orthopedic surgery has emerged to

become one of the most exciting, robust, and rewarding fields
in medicine. Not surprisingly, it has become one of the most
desired and competitive residency programs in America and
around the globe. To better understand the competitive nature
of this field, we refer to the 2010 National Residency Matching
Program (NRMP) report. Based on the results of the 2010 NRMP
Orthopedic Surgery Program Directors Survey, programs in
orthopedics received 457 applications on average, of which
only 54% passed the initial screening and were reviewed in
depth, while 46% were simply rejected. Of the remaining
pool of applicants, 58 were interviewed for only four available
residency positions, on average.1 In 2013, there were less than
0.7 orthopedic residency positions available for each applicant
who listed an orthopedic surgery program as their preferred
specialty on the rank list.2 Furthermore, according to the
2011 NRMP Charting Outcome of the Match, the US medical
student seniors who matched into orthopedics had a mean
United States Medical Licensing Examination (USMLE) Step 1
score of 240; 27.1% were Alpha Omega Alpha (AOA) members;
and most were highly involved in research with a mean of
4.5 abstracts, presentations, and publications.3 This clearly, but
xx Orthopedic Residency Guide
not fully, illustrates the level of difficulty for gaining acceptance

into an orthopedic residency.
Which factors contribute to the competitiveness of this
field and what are the implications for interested candidates?
Perhaps, it is only after fully understanding the competitive
nature of this field that interested candidates can more
realistically approach the challenges and plan accordingly.
Several factors account for the exceedingly competitive
nature of orth opedic residency programs. Foremost,
orthopedic surgery by nature is an exciting, interesting,
and robust field in medicine. The world of orthopedics,
with its numerous fascinating surgical and nonsurgical
approaches to musculoskeletal conditions and deformities,
intrigues many people. The recent, increasing trend and
engagement in evidence-based medicine and cond ucting
quality basic science and clinical research has brought even
more excitement and shone more light onto the science of
orthopedics. This has translated into the introduction of
novel techniques and instrument designs and more effective
management of disorders, with the ultimate goal of improving
the quality of patient care. The field of orthopedics has grown
out of its infancy and become a giant field in medicine as
a result of the exponential number of advancements and
discoveries.
Additionally, most orthopedic procedures currently
have some of the highest ratings for success and patient
satisfaction among all types of surgical operations. This
success has been made possible by a combination of excellent
outcomes, relatively minimal complications, low morbidity
and mortality, and long-lasting results. Besides the low
complication rates, the recovery and functionality rates after
orthopedic operations are remarkable in most cases. These
factors ultimately equate to high patient satisfaction rates
and the desire to seek various elective orthopedic procedures.
For example, hip and knee arthroplasty operations have
Introduction xxi
become two of the most successful and sought-after surgical
procedures performed in the US today.
The demand for orthopedic surgeons will continue to
rise dramatically in the next two decades, as the baby boomer
generation ages. Because of advances in medical technology,
we now live far longer than our ancestors did. Inevitably,
the notion of longevity fosters the presumption of continued
preserved health. However, in reality, medically-achieved
longevity exposes our musculoskeletal system to greater
wear and tear and a greater need for repair. Today, the elderly
engage in a higher and more diverse level of recreational and
outdoor activities, further necessitating a more functional
and healthy musculoskeletal system. Consequently, the
above factors have resulted in a greater demand for both
elective and nonelective orthopedic procedures in the elderly
population. Patients in their seventh or eighth decades of life
more frequently elect to undergo arthroplasty procedures,
once a rarity for patients in this age group.
Finally, global urbanization, most often a result of
rapid, unplanned growth and global modernization, plays
a role in the rising demand for orthopedic surgeons. As
a consequence of urbanization, urban populations face
greater health hazards than before. As an example, the
overcrowding of cities puts people at increased risk of
becoming involved in motor-vehicle-related accidents and
sustaining injuries that necessitate orthopedic care. Similarly,
continued suburbanization growth has been associated with
increased poverty and limited access to specialty care such as
orthopedics to those in need in many regions.
Despite the increasing demand for orthopedic surg
eons, the number of orthopedic residency positions and
subsequently, the number of orthopedic surgeons will not
increase at nearly the same rate. For example, the number
of orthopedic surgery positions in 2010 increased by a
mere 6.25% from 5 years ago,5 while demand for orthopedic
xxii Orthopedic Residency Guide
procedures such as arthroplasty have increased, and will

continue to rise, much more drastically in the next two
decades.4-6 In summary, a combination of supply and
demand, and the exciting, rewarding nature of orthopedic
surgery accounts for the popularity and competitive nature of
this field.
As fields such as orthopedic surgery have become more
competitive, residency programs have developed more
stringent methods to compare and screen applicants. The
USMLE board scores, AOA membership percentile, and
research involvement for candidates who are matched into
orthopedic surgery programs are the highest among all
specialties.
As an interested candidate for orthopedic surgery, you
may have many unanswered questions, such as: “What are
the most important selection criteria for orthopedic surgery
residency programs?”, “Am I competitive enough for this field,
and what can I do to make myself more competitive?”, “Do I
have a chance if I scored poorly in my USMLE Step 1?”, “How
important is the role of research involvement?”, and many
others. It is our goal for this book to answer questions you
may have about applying for orthopedic surgery residency
in the most detailed and comprehensive manner. This
book will reveal the truth and secrets to a successful match
in orthopedic surgery, which may also be applied to other
competitive medical residency programs.
References
1. National Resident Matching Program, Data Release and
Research Committee: Results of the 2010 NRMP Program
Director Survey. National Resident Matching Program, Wash-
ington, DC: 2010.
Research Committee: Results and Data. National Resident
Matching Program, Washington, DC: 2013.
Introduction xxiii
3. National Resident Matching Program, Data Release and Re-
search Committee: Charting Outcomes in the Match. National
Resident Matching Program, Washington, DC: 2011.
4. Day JS, Lau E, Ong KL, et al. Prevalence and projections of total
shoulder and elbow arthroplasty in the United States to 2015.
J Shoulder Elbow Surg. 2010;19(8):1115-20.
5. Fehring TK, Odum SM, Troyer JL, Joint replacement access in
2016: a supply side crisis. J Arthroplasty. 2010;25(8):1175-81.
6. Kurtz SM, Lau E, Ong K, et al. Future young patient demand
for primary and revision joint replacement: national projec-
tions from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):
2606-12.
1
The History of
Orthopedics
Jonathan B Macknin
The history of orthopedics dates back to the stone age when

early man splinted fractures to provide an immediate form of
pain relief and to allow for better function once the fracture
had healed.1 While we have made many advances since these
rudimentary splints, it is important to understand the rich
history of orthopedics to fully appreciate what we are able
to do for patients today and what we hope to do for them in
the future.
Research on the skeletal remains of Neolithic people
shows that over 50% of arm and leg fractures displayed
evidence of healing. The healing and alignment of the bones
led researchers to conclude that the fractures had been
splinted.1 While there are no physical remains of these primi-
tive splints, it is thought that they were likely made up of bark
and sticks secured to the extremities. There is later evidence
of splints made from clay in South Australia and moistened
rawhide in the Americas.2 These splints hardened as they
dried, providing a stable environment to allow for bone
healing. In these societies, designated tradespeople dealt with
orthopedic issues.
2 Orthopedic Residency Guide
In 1900 BCE Babylon, the code of laws regulated

medical practice for bonesetters, dentists, and slave branders
known as “gallabu”.2 It is believed that much of the teachings
of bonesetting were passed on orally during this time. The first
evidence of written teachings appears on a papyrus dating
from 1600 BCE Egypt, which was discovered by Edwin Smith.
This papyrus reviews many tools for diagnosis and treat-
ment of orthopedic injuries. Below is a translated excerpt
describing the treatment of a broken arm.
Thou shouldst place him prostrate on his back, with
something folded between his two shoulders in order to
stretch apart his upper arm until that break falls into place.
Thou shouldst make for him two splints of linen, and shoul-
dst apply for him one of them both on the inside of his arm,
and the other of them both on the underside of his arm. Thou
shouldst bind it with a mineral substance and treat it after-
ward with honey every day until he recovers.2,3
Ancient Greece has made numerous contributions to
medicine, specifically to the field of orthopedics. Seminal
work was done with documenting human anatomy, allowing
for deeper understanding of orthopedic ailments. The Hippo-
cratic corpus, a series of texts written between 430 BCE and
330 BCE, made many contributions to orthopedics. Many
sections are devoted to diagnosis and treatment of bone
fractures and dislocations.2,4-6 Topics such as clubfoot correc-
tion and open fractures are also explored. Hippocrates and his
followers demonstrated an excellent understanding of frac-
tures through their use of traction and countertraction, as well
as specially designed splints for specific fracture patterns.5,7
The texts of Hippocrates advocated the use of biomechanics
for reducing shoulder, knee, and spinal column injuries.4
The teachings of the ancient Greeks were furthered by
Galen during the Roman era (129–199 CE). Galen has been
referred to as “the father of sports medicine” because of
his devotion to the treatment and research of injuries to
The History of Orthopedics 3
gladiators and other athletes.5,6,8,9 Galen described bone infec-
tion and its different stages as well as potential treatments in
an era before antibiotics. He is also believed to have been the
first to label the spinal deformities previously described by
Hippocrates using terms that are still commonplace today.7
The Greco-Roman teachings were followed for centuries with
little evidence of change during the middle ages.1
Some of the slow growth in the field of orthopedics
during this period is attributable to the role of the church in
society.2 Church leaders worried that, if medical treatments
failed, the clergy members responsible for the medical care
would be blamed, causing conflict against the church. It was
this worry that led the church to ban priests, monks, and
later physicians from attending public medical lectures.2
During this time, only barbers could perform surgery.
However, in 1540 Thomas Vicary helped unify the barber
and surgeon guilds and outline the duties of the barber-
surgeon versus the physician (who would sometimes over-
see the barber-surgeons).2 It was not until the 15th and 16th
centuries that the development of orthopedics and medi-
cine advanced beyond the teachings and philosophies of the
Hippocrates era.5,6
This period saw the production of an immense amount
of literature and work on human anatomy, from Leonardo
da Vinci (1452–1519) to Vesalius. Leonardo da Vinci contri
buted a large body of original work on the origin, insertions,
and functions of skeletal muscles. This led to the principles of
mechanical leverage and muscle balance in the human body.
Vesalius’s work De Humani Corporis Fabrica, published in
1543, details the musculoskeletal system with great accuracy.7
Ambroise Paré (1510–1590) is one of the most influential
figures in surgery of the 16th century, publishing books that
were translated into numerous languages. In fact, he is known
as the “father of modern surgery” because of his numerous
contributions to the field. Paré described many new and
modified surgical techniques, including the use of tourni-

quets and the ligature of blood vessels in amputations. He
also assisted in the design of many instruments and braces, as
well as prosthetics made from iron.6,7
Clopton Havers (1657–1702), an English physician,
devoted his work to the anatomy of bones and joints. His
book, The Osteologia Nova, includes the first known descrip
tion of Haversian canals in bones as well as the microscopic
characteristics of cartilage and bone. It should be noted,
however, that he did not recognize the vascular nature of
Haversian canals.7
Albreght Von Haller (1708–1777) studied the physiology
of the human body as well as the formation of bone. He noted
that muscle contractures are initiated by nerve signals; he
created the initial microscopic description of bone formation
and fracture healing, and showed that nerves are necessary
for sensation.7
In 1741, Nicolas Andry published his famous book,
L’Orthopédie, in which the word orthopaedic was used for the
first time.
As to the title, I have formed it of two Greek words,
orthos, which signifies straight, free from deformity, and
paedis, a child. Out of these two words, I have compoun
ded that of Orthopedia to express in one term the design I
propose, which is to teach the different methods of preventing
and correcting the deformities of children.10
His creation of the term orthopedics and his illustration
of a tree tethered to a pole, which is now a universal symbol
associated with the field, make him a key figure in the history
of orthopedics.2,5,7,11
Jean-André Venel (1740–1791) was the first physician to
create an orthopedic hospital that focused on the treatment
of crippled children in a systemic fashion. The hospital han-
dled the medical as well as social needs of crippled children.
He is considered by some to be the father of orthopedics in
the original spirit of the word because of his multidisciplinary
approach in treating the crippled child.2,11
Several key events in the 18th and 19th centuries helped
to transform orthopedics from the treatment of childhood
deformities into what it is today. In 1796, Edward Jenner
proved that exposure to cowpox provided immunity to small-
pox. This opened the door to vaccines and the exponential
reduction of infantile paralysis, giving orthopedic surgeons
time to focus on other diseases and injuries. In addition, the
development of anesthesia for surgery allowed for safer, less
painful procedures. In approximately 1799, Humphrey Davy
stated that anesthesia “…may probably be used to advantage
during surgical operations in which no great effusion of blood
takes place”.12 Unfortunately, no further investigations were
done at that time and it was not until a dentist, William Mor-
ton, publicized his use of ether as a surgical anesthetic that its
use became commonplace. The developments in infectious
diseases and bacteriology led by Joseph Lister, Louis Pas-
teur, Robert Koch, and Paul Ehrlich allowed for significantly
safer operations due to the use of antisepsis and aseptic tech-
niques. In 1895, Wilhelm Roentgen’s discovery of X-rays for-
ever changed the orthopedist’s ability to diagnose and treat
bone-related diseases and trauma.5-7,13

Robert Jones (1857–1933), a British orthopaedist,
became the head surgeon of the Manchester Ship Canal cons
truction project in 1888. This position allowed him to set up
multiple surgical centers along the length of the canal to han-
dle injuries of the 20,000 workers. Because of the high volume
of orthopedic injuries these clinics dealt with, he became
an expert in fracture management, to the point that physi-
cians from around the world came to learn from him. He was
appointed organizer of the British Army’s orthopaedic servic-
es. Following World War I, he assisted in creating many ortho-
pedic hospitals and founded the British Orthopaedic Associa-
tion in 1918. Robert Jones and his uncle, Hugh Owen Thomas,
are credited by some as being the men who expanded ortho-

pedic practice to include fracture management and treatment
of adults.2,14
The advent of hip surgery in the 1900s marked a mile-
stone in modern orthopedics. Gathorne Robert Girdlestone
first described a surgery to treat and release a fused tubercu-
lous hip in the 1920s. The cup arthroplasty was invented by
Marius Nygaard Smith-Peterson in the 1930s. The innova-
tion of a total hip replacement by John Charnley in the 1960s
has proven to be one of the most successful innovations in
modern orthopedic surgery. In 1970, John Insall developed a
total knee prosthesis that serves as the foundation for the
total knee prostheses designs used today.
The development of internal fixation for fractures from
the 1900s to today has had a profound impact on how frac-
tures are managed and on end-patient outcomes. The early
proponents of surgical fixation of fractures, instead of the
splinting and traction devices traditionally used, were Elie
and Albin Lambotte, Robert Danis, Fritz König, William Lane,
and Gerhard Küntscher. Robert Danis is credited with first
using the term “osteosynthesis”, osteo meaning “bone” and
synthesis meaning “combining separate materials or ele-
ments into a unified entity”. The term “osteosynthesis” now
applies to operative techniques ranging from plates and
screws to nails.15
In 1940, Gerhard Küntscher, a German surgeon,
described a new technique of intramedullary nailing, which
consists of inserting a nail down the marrow cavity of bone
for treating femur fractures. Similar methods had been
undertaken using a smaller rod by L V Rush and H L Rush
in the 1930s, but its use was not the standard of care at the
time. Küntscher’s technique of intramedullary nailing allo
wed for nearly immediate weight bearing for a fracture that
traditionally required 6–8 weeks of bed rest and traction. This
technique became widespread following World War II and
remains the standard of care today.12,15
Another commonplace orthopedic procedure used
today is arthroscopy. Arthroscopy was first described by
Kenjii Takagi in 1918, in which he used a cystoscope to exam-
ine the knee joint of a cadaver. By the 1930s, he had the abil-
ity to take color photographs of the joint through the use of
arthroscopy. Equipment issues prevented arthroscopy from
becoming commonplace until Masaki Watanabe developed
a better arthroscope in the late 1950s. He performed the first
arthroscopic procedures, including a partial meniscectomy.
Today, numerous other procedures and disorders in many
other joints benefit from the advances in arthroscopic equip-
ment and techniques.13
All of these advances prove that orthopedic surgery is
a constantly evolving field. It is influenced by evolving tech-
nologies in radiology, metallurgy, and computer technology,
and will continue to advance quickly in the future with new
technologies and evolving medical research. Despite these
advances and changes, however, the reputation of orthopedic
surgeons as bonesetters will remain.2
REFERENCES
1. Woods M, Woods MB. Ancient Medicine: From Sorcery to
Surgery. Minneapolis, MN: Runestone Press; 2000.
2. Beckett D. From bonesetters to orthopaedic surgeons: a
history of the specialty of orthopaedics. The Surgical Techno
logist. 1999:7-10.
3. Bishop WJ. The Early History of Surgery. London: R. Hale;
1960.
4. Mow VC, Huiskes R. Basic Orthopaedic Biomechanics and
Mechano-Biology. Philadelphia, PA: Lippincott Williams &
Wilkins; 2005.
5. Brakoulias V. History of Orthopaedics. [online] World Ortho
website. Available from http://www.worldortho.com/dev/
index.php? option=com_content&view=article&id=143&Item
id=8 Published 2007. Accessed December 18, 2011.
6. Riedman SR. Masters of the Scalpel: The Story of Surgery.

Chicago, IL: Rand McNally; 1962.
7. Ponseti IV. History of orthopaedic surgery. Iowa Orthop J.
1991;11:59-64.
8. Snook GA. The father of sports medicine (Galen). Am J Sports
Med. 1978;6(3):128-31.
9. Bendick J. Galen and the Gateway to Medicine. Nashville, TN:
Bethlehem Books; 2002.
10. Bois-Regard NA. Orthopaedia. Philadelphia, PA: JB Lippin-
cott; 1961.
11. Peltier LF. Orthopedics: A History and Iconography. San Fran-
cisco, CA: Norman Pub; 1993.
12. Davy H. Researches, chemical and philosophical-chiefly con-
cerning nitrous oxide or dephlogisticated nitrous air, and its
respiration. Bristol: Biggs and Cottle, 1800.
13. Kennedy M. A Brief History of Disease, Science, and Medicine:
From the Ice Age to the Genome Project. Cranston, RI: Writers’
Collective; 2004.
14. Green SA. Orthopaedic surgeons. Inheritors of tradition. Clin
Orthop Relat Res. 1999(363):258-63.
15. Kellam J, Boer PG, Jann U, et al. Transforming Surgery, Chan
ging Lives: The First 50 years of the AO. Druckerei Odermatt
AG; 2008.
2
First and Second Year
of Medical School
Golta Rasouli, Sean E Mazloom, Stephanie Krema
Congratulations on making it into one of the most competitive

graduate programs. You should be very proud of yourself—all
of your hard work and planning have resulted in this great
accomplishment.
Choosing a medical specialty is one of the biggest deci-
sions you will ever have to make. Since this is what you will be
doing for the rest of your life, you need to be sure that it is the
best choice for you. Yet, because of little or no clinical expo-
sure, most first- and second-year medical students are unable
to identify their field of interest. We will make recommen
dations on how to make this an easier task. Do not be stressed
if you have not made a decision by your third year.
The overarching theme of our recommendations is to
maintain this perspective—strive for top grades while prepa
ring yourself for the clinical years ahead. In this chapter, we
will address the most important issues to help you make the
best out of your first 2 years.
During this time, you will form a knowledge foundation
upon which you will continue to build. Of course, there will
be times of incredible frustration with the workload and you
will wonder if you can ever succeed. There will also be times
when you will question the purpose of studying certain sub-

jects, as they may appear trivial, tedious, or irrelevant. But
remember that by understanding the relationship between
these different subjects, you will become a critical thinker
and problem-solver regardless of which field of medicine you
ultimately choose.
Diligent studying, on the other hand, will allow you to do
well both in school and in the United States Medical Licensing
Examination (USMLE). It is crucial for an applicant conside
ring orthopedic surgery to know that high USMLE scores
are a major selection criterion, as are top grades in basic
sciences. Your goal is to have a solid foundation of knowledge,
which is seen objectively in conjunction with your grade point
average (GPA). In general, students who do well academi-
cally and are in the top of their class tend to do better on the
USMLE examinations and are chosen for Alpha Omega Alpha
(AOA). We will address USMLE preparation and AOA memb
ership later in this chapter.
MASTERING AND ACING THE

BASIC SCIENCE COURSES
Medical school is different from undergraduate school in
several aspects. To begin with, you must learn and master a
far larger volume of material in a shorter period of time.
Consider how you are expected to learn all the basics of medi-
cine in less than 2 years! It is daunting but possible.
Whether organ-based or systems-based, you will study
the core subjects: physiology, anatomy, biochemistry, cell
biology, genetics, neuroanatomy, behavioral science, histo
logy, embryology, micro biology, immu nology, pharma
cology, and pathology, all within the first 2 years of medical
school.
In addition to classroom courses, clinical exposure
begins during the first year as well. The amount and extent of
clinical learning varies according to the institution.
First and Second Year of Medical School 11
Not only is there a larger workload than in undergraduate
courses, but you must be ready to master this material in
mind-boggling detail. However, it is not so bad if you keep in
mind that this detail is to train you to treat real people. Always
remember that besides doing well in school and in USMLE
examinations, more knowledge means better care for your
patients should be your primary goal.
Some levels of confusion, frustration and anxiety early in
medical school are expected and understandable. Many stu-
dents will find themselves getting behind even in the first few
weeks of medical school. The key to surviving mentally and
academically is to know that this is not uncommon. It is okay
to struggle in the beginning. Identify your weaknesses early
and do not be ashamed to ask for help. Students who ask for
help early on tend to become very successful students. Profes-
sors, advisors, deans, and more senior students are all great
resources—ask as many people as possible for help.
Academic success in medical school requires planning,
perseverance, and persistence. Forcing yourself to study
12 hours a day may not suffice. Ultimately, top grades, top
USMLE scores, and AOA membership requires systematic
time management plus using the right study materials for you.
From day 1, make it a habit to create a study schedule.
Start with a weekly or daily schedule; adjust time allotments
as needed until you are comfortable with the amount of
material covered. You will maximize your efficiency when you
know exactly how much material you can absorb in a certain
amount of time. You can then “guesstimate” what needs to be
covered each day, each week, and each month, and gauge if
you are falling behind in your coursework. Some who rigidly
follow their study schedules will find themselves finishing
readings earlier than the class schedule.
Repetition is key to memory; cover more than one sub-
ject each day, preread before lecture, review the material after
lecture, and review it again within a week. This tried-and-true
method solidifies newly learned material. Indeed, it is the key

to mastering this massive volume of data in medical school.
Finally, never forget to include adequate break time between
study blocks.
Another important question raised by medical students
is which resources to use. There are countless textbooks,
review series, and preparation courses available. There are
school lecture notes and assignments that are either encour-
aged or mandatory. With such an overabundance of reso
urces, it is easy to lose valuable time and money.
Although there is no single perfect book or series, several
strategies can help you to ace school and USMLE examin
ations. First, know your learning style. You can maximize
retention by appropriately selecting the study material that
will specifically serve your needs.
In general, school-recommended textbooks and lecture
notes provide comprehensive coverage of all subjects. These
resources will provide the most detailed explanations. On the
other hand, review books and USMLE preparation courses
focus on high-yield material, meaning the more commonly
tested facts. Of course, there is not just enough time in medi-
cal school to use all available resources. Narrow down your
sources to a manageable two or three, those that provide you
the most inclusive yet high-yield material.
Each course has both required and recommended text-
books, which you should investigate prior to purchasing
them. Most required textbooks are well known and may be
extremely beneficial. By providing a more comprehensive
picture, textbooks provide the reasoning and understanding
behind concepts and facts; purely memorizing concepts with-
out a thorough understanding is not recommended and will
not lead to high scores. The reasoning as to “why” things are
the way they are will enable you to learn and master material.
Lecture notes vary in the level of importance from one
lecturer to another and from one institution to another.
In other words, some lecture material may be tested exten-
sively on school and USMLE examinations, while some of it
may be merely of interest to the professor. It is recommended
that you read and learn the lecture material well, as professors
like to question students on the lecture materials and notes.
However, some lecture notes may not be as high-yield or use-
ful for the USMLE. Therefore, it is your responsibility to find
out how useful lecture notes are.
More senior students at your school are the best
resources. Do not underestimate the value of previous stu-
dents’ experiences. This is the time for you to improve upon
their mistakes. Find friends among students and alumni; they
will doubtless provide you with priceless advice on how to
succeed in both medical school and residency.
You should note that the grading system varies among
medical schools. There is the pass/fail schema, the traditional
five-interval scale (A, B, C, D, and F), a four-interval scale
(A, B, C, and F), and other schools use a modified pass/fail
system (honors/high pass/pass/fail).
In summary, we recommend that you use two or more
resources, including high-yield books, textbooks, and lecture
notes, to achieve the most in-depth understanding of the
learned material, which will lead to high scores.
SECOND YEAR OF MEDICAL SCHOOL AND

USMLE PREPARATION
There are three components to mastering the USMLE exami-
nations: Step 1, Step 2, and Step 3. They are each referred to
as “The Boards”. Step 1 evaluates your knowledge of the basic
sciences and its clinical correlation and is taken at the end of
second year. It is required that you pass Step 1 before begin-
ning clinical rotations.
Step 2 is split into two parts: clinical knowledge (CK)
and clinical skills (CS). Step 2 CK is the more difficult of the
two and has a format similar to that of Step 1; it assesses your

increasing clinical knowledge and focuses far less on the
details of basic sciences. Step 2 CK is taken between the end
of third year and the middle of fourth year. Step 2 CS is an
interactive test that focuses on patient interaction, English flu-
ency, and communication skills. You must pass Step 2 CK and
CS before starting residency. Step 3 is another computerized
examination taken at the end of intern year to assure that you
can work independently in providing the standard of care for
your patients.
The key to success in second year follows the same prin-
ciples—hard work and excellent academic performance. We
advise that halfway through second year you start to review
your first-year courses, as you will generally not have enough
time before Step 1 to review all of them. By starting with more
conceptual subjects (such as physiology) and leaving the
more memorization-centric subjects (such as biochemistry)
closer to the test date, you can retain the most volume. We
also recommend that you start practicing questions around
the same time, halfway through second year.
As fields such as orthopedic surgery have become
more competitive, programs have developed more stringent
methods to compare and screen applicants. Most incoming
orthopedic residents have done very well academically and
clinically. Many also have extensive research involvement
with publications, conferences, and presentations on their
curriculum vitae (CV).
Step 1 and 2 scores are the only standardized examina-
tions for allopathic medical students. While the purpose of the
USMLE is to assure preparedness for medical licensure, these
examinations are also the primary method of comparing
students from different schools and educational backgrounds.
Therefore, our recommendations for second year is not much
different—do well in school and in the USMLE.
What if you did not achieve top grades in your basic
science courses? Do not get discouraged if you did not per-
form as you hoped. If first year was difficult for you, then
improve your grades during your second year by identifying
your weaknesses and improving study skills. If both first and
second years proved to be problematic for your GPA, you still
have a chance to succeed.
Indeed, regardless of your less-than-satisfactory results,
you can still make yourself competitive in several ways: get
a high score on Step 1 (most important), get a high score on
Step 2, get top grades in your third-year rotations, and get
involved in orthopedic research. Involvement with research
has been known to help minimize a disappointing GPA.
USMLE REVIEW BOOKS AND

PREPARATION COURSES
Besides textbooks and lecture notes, there are many helpful
review series (First Aid, Kaplan, Rapid Review, Ridiculously
Simple, and Step Up to name only a few). However, with so
little time, you need to be selective in using them. Consider
your learning style. Do you need color photos or are black-
and-white sufficient? Do you prefer information bullets or
prose? Do you prefer the writing style of a particular author or
series? These are all seemingly silly, yet important qualities to
remember when selecting a study guide.
“First Aid” for the USMLE Step 1 is considered an
essential high-yield source. However, it is not sufficient to
use alone. Use it in addition to your lecture notes, textbooks,
or other high-yield books. Adding your own notes to “First
Aid” will make it more comprehensive and therefore more
valuable to you personally. Many other great review books are
out there and the authors of this book recommend full inves-
tigation into the best sources for you.
Besides review books, there are several USMLE prepara-

tion courses worth looking into. Historically, they were used
primarily by international medical graduates (IMGs) seeking
to improve their chances at entering the American system.
Lately, more American medical students are participating as
well. The courses are costly, but may be worth it if you perc
eive weaknesses in your knowledge. They are specifically
designed to prepare you for the Steps 1, 2, or 3 and are offered
in a variety of formats: live lectures, online courses, books, and
videos. Once again, we recommend that you investigate whe
ther these courses are for you. You should look into it early in
your first year to benefit from it throughout medical school.
USMLE PRACTICE QUESTIONS

Similar to review courses and books, there are several
resources for practice questions for Step 1 and Step 2 CK.
USMLE World and Kaplan questions are the most commonly
used question banks (Qbanks) but others are worth look-
ing into. Regardless of which Qbank you use, it is important
to start practicing questions halfway through the second
year. More importantly, make sure you spend enough time
going over the explanations for both the wrong and the correct
answer choices. Recognize why you chose a specific answer.
The National Board of Medical Examiners (NBME) is
the organization in charge of writing USMLE questions. The
NBME offers multiple practice examinations that will assess
your preparedness for Step 1 and Step 2 CK. Be sure to take the
most recent examinations, as they most closely represent the
information tested on the actual examination.
SCHEDULING YOUR
STEP 1 EXAMINATION
Because each school has a slightly different scheduling sys-
tem for the end of second year and the beginning of third-year
rotations, exactly when to schedule Step 1 is a question best
answered by your school. Some students take Step 1 before
second year classes have ended, while others require far more
preparation time and take it days before rotations begin. In
the meantime, you can check the following websites for more
information: www.nbme.org and www.usmle.org/exami-
nations/step1/step1.html.
We recommend that you register for Step 1 early. You
will first choose a 3-month period in which to take your
examination. You can move the exact date around on the
scheduling website or by calling, but the date must be within
that 3-month period. Finally, when scheduling your exami
nation, be sure to give yourself at least a week off for vacation
and rest before starting third-year rotations.
ALPHA OMEGA ALPHA HONOR

MEDICAL SOCIETY
Alpha Omega Alpha recognizes and advocates for excellence
in scholarship and the highest ideals in the perfection of
medicine. It is one of the most prestigious medical societies to
which one can be elected. The top 25% of the medical school
class is eligible for nomination. Students can be elected to
AOA during third or fourth year.
It is worth mentioning that up to 16% of nominees will
be chosen based on leadership, character, community ser-
vice, and professionalism. However, for most students to join
AOA, academic excellence in medical school is the key to
nomination.
Alpha Omega Alpha membership is highly regarded
during the interview selection criteria—27.8% of orthopedic
surgery incoming residents were members of AOA in 2009
(Charting Outcomes for the Match, National Resident Match-
ing Program, 3rd edition, 2009). Moreover, AOA membership
provides additional resources such as research scholarships,
conferences, and networking opportunities for members.
For additional information regarding AOA, visit their website:

www.alphaomegaalpha.org.
EXTRACURRICULAR AND
SOCIAL ACTIVITIES
Extracurricular and social activities are an important yet
underappreciated part of the medical school. As a rule of
thumb, participate in those activities that you enjoy the most.
It is essential to continue with your hobbies during medical
school to ensure mental and physical balance. It is always
practical to think of what activities you used to do before
medical school for fun and simply continue doing them. It
may seem obvious now, but medical students are notorious
for losing perspective; without a stress-reliever, you will easily
burn out.
It is also important to participate in all activities planned
by school or your classmates during orientation week
before classes start. This is the best time—and perhaps the
only time—to meet most of your classmates. This is when
everyone is still stress free and relaxed enough to get to know
each other personally. The friends you make in the first few
weeks of medical school will likely compose your main circle
of friends until graduation.
Every student needs a strong support system during
medical school. This cannot be stressed enough. To stay sane,
you will need someone with whom you can spend time, study,
and rely on. As a bonus, having one or two study partners will
make studying more effective and fun.
ORGANIZATIONS AND CLUBS

When it comes to organizations and clubs, students
always wonder about which to join and how many is a good
number to have on their CV. Schools usually have dozens of
different clubs and organizations, most medical and some
nonmedical. We suggest that you familiarize yourself with
these clubs early on. Compared to second year, you will have
much more time during your first year of medical school to
dedicate to extracurricular activities.
Which club to join should be based on your interests. Do
not join a club because you think it may look good on your CV.
What looks good on a CV is showing that you took initiative
in joining a club with a humanitarian mission, ideally with a
leadership position.
You should get involved in at least one club associated
with orthopedic surgery, as well as each concentration you
are seriously considering as a career. Your goal should be to
get involved in something that you enjoy.
Besides orthopedic interest groups, consider mem
bership in other surgical clubs, which often offer suture and
casting workshops. This will be a great opportunity for you to
learn more about the field, get in touch with orthopedic sur
geons in the community, and form a network with classmates
interested in orthopedics. If there is no orthopedic surgery
club at your school, then this is a great opportunity for you to
start one. Remember, less is more when it comes to clubs so
that you can fully devote your time and make a difference.
SHADOWING PHYSICIANS
Shadowing simply means volunteering to follow a physician

in the office, clinic, hospital, or operating room. Your goal
should be to learn about their profession by observing their
daily tasks, doctor-patient interactions, and types of pro-
cedures performed. Again, during the first year of medical
school, you will have the most amount of time for such extra-
curricular activities.
If you are unsure about whether to pursue orthopedics,
we highly recommend shadowing physicians in both surgi-
cal and nonsurgical fields. You have many options in which
to specialize—it is best to see and experience them first hand

before making up your mind.
Your decision on which field of medicine to go into
should not be solely based on what you have read or what you
have heard from friends, family, or classmates. Instead, you
will benefit the most by seeing, experiencing, and learning
about it yourself. Most physicians love to teach if you show
your interest. All you need to do is take the initiative to con-
tact different physicians. Most schools have a list of doctors
who are interested in shadowing opportunities. It will help
you choose your field of interest by opening up or ruling out
the possibilities. The sooner you decide on a specialty, the
better you can prepare yourself for the residency applications.
This is especially essential for competitive fields like ortho
pedic surgery.
3
Keys to Success in the
Third Year of Medical
School
Sean E Mazloom, Eugene Y Tsai
CLINICAL ROTATIONS
Congratulations on finishing two intensive years of basic
science courses. Many students see those as the most difficult
years of medical school. Most of you have also taken a tremen
dous weight off your shoulders by taking your United States
Medical Licensing Examination (USMLE) Step 1 examination.
Although you will always be reading and studying for different
examinations, you are officially finished attending classes.
You are now ready to begin practicing the aspect of medicine
that draws most people to this profession, i.e. working with
patients. In transitioning to the second half of medical school,
your roles and responsibilities drastically change from being a
classroom student to being a member of the healthcare team.
Your everyday job changes from studying for hours every day
to being responsible for the well-being of your patients. This
is a major shift from what you were trained for and did up
to now. Thus, a smooth transition and success on your
clinical clerkships requires planning and preparation. In this
chapter, our goal is to give you an overview of your third year
of medical school and advice on how to do well on wards.
It is essential to know that in the orthopedic resi

dency selection process, receiving honors in your third-year
clerkships is weighted more heavily than the grades you earn
during your first 2 years of medical school. In fact, based on
the 2010 National Resident Matching Program (NRMP) sur
vey of program directors, honors in the third-year clerkships
is considered the single most important factor used by the
majority of orthopedic residency program directors in rank
ing applicants.1 In comparison to receiving honors in a basic
science course, it has been shown that excellent performance
on clinical rotation is a better indicator of success during
residency. Some reasonably argue that because of substantial
variability in the grading systems of the third-year clerkships
among different institutions, it may not be the most reliable
indicator of future performance in residency.2
Now is your chance to prove that you are clinically well
prepared and ready to take on the responsibilities of an
orthopedic resident by striving for excellence and achieving
honors in clerkships, even if achieving honors was not a regu
lar occurrence for you in the first 2 years of medical school.
Conversely, poor performance on your clinical clerkships can
easily nullify your first 2 years of hard work.
Most medical schools require the following core clerk
ships to be completed by the end of the third year: inter
nal medicine, surgery, obstetrics/gynecology, pediatrics,
and psychiatry. Besides these, some schools require taking
neurology, emergency medicine, and family medicine in the
third year. We will address each of these rotations separately
in this chapter.
The order of your rotations does not matter, as long as
you work and study hard for each. However, there are some
theoretical advantages to having certain rotations at particu
lar times of the year. During your first one or two rotations,
you will be adjusting to working in the hospital environ
ment. For some people, this is a quick and easy transition; for
Keys to Success in the Third Year of Medical School 23
others it takes some time to adjust before they are able to
shine. Because of this, many students prefer to start with a
type of medical rotation in which basic skills such as floor
work and patient presentations are emphasized. In addition,
the surgery rotation tests a fair amount of medical knowl
edge. Taking a potential rotation of interest in the earlier half
of the year is often preferable for several reasons. Third year
can be an exhausting experience and many students begin
burning out toward the end of the year. In addition, doing an
orthopedic surgery elective at this time is a great time to con
nect and form relationships with the department, attending
surgeons, and residents. It is a great chance to begin getting
involved in research projects. The earlier this happens, the
more you can accomplish. Another consideration is plan
ning subinternships for the fourth year. Subinternships both
at your home program and at away programs are a major part
of applying to orthopedic surgery residency. The process of
applying for subinternships begins in the last few months of
third year before you have completed all your rotations. This
means that by the time programs begin accepting applica
tions for away subinterns, you have to know that you want to
do orthopedics, particularly if you want to apply to the more
popular programs. Overall, the order in which you take your
clerkship rotations is of far less importance than it is to show
that you are a hardworking, motivated, and smart team player.
It is a general misunderstanding that if you are going into
a surgical specialty you only need to do well in your surgical
rotation(s). This is a mistake that you should avoid at all costs.
Regardless of your interests, you must work hard and learn as
much as possible in each of your rotations for several reasons.
First, these rotations are your best and likely last opportu
nity to get to learn and experience each particular specialty
of medicine firsthand. Regardless of the scope of your future
practice, becoming familiar with a broad spectrum of medi
cal conditions will serve you well in providing the optimal
care for your patients. The prevalence of chronic, debilitating

conditions such as diabetes, obesity, and hypertension, along
with their associated comorbid issues and complications,
necessitates that doctors in any field have expertise in or at
least familiarity with the needs and requirements of such
patients. Your pediatric, obstetrics/gynecology, and psychia
try rotations enable you to learn how to interact and treat
patients in these specific categories. To be deserving of the
title of doctor, one is expected to be versed in all aspects of
medicine. As an orthopedic surgery candidate, you must
show academic and clinical excellence consistently through
out medical school. As mentioned before, receiving honors
in as many of your third-year clerkships as possible is a criti
cal component of the residency selection process. It shows
that you have adaptability, a broad range of knowledge, and
a wide range of skills to manage and treat patients of all ages
with varying medical and psychological conditions. When
programs consider your paper residency applications, there
are three categories they rate each candidate on: (1) grades,
(2) USMLE Step 1 score, and (3) research involvement. Your
job in medical school is to excel in each of these categories.
During the interview process, you are rated in a fourth cat
egory, which is personality.
KEYS TO SUCCESS DURING

YOUR CLINICAL ROTATIONS
As mentioned earlier, there is a vast difference between the
first 2 years of medical school and the rest of your medical
education. You need to be prepared and plan ahead accor
dingly, not only for a smooth transition but also for success
ful completion of your clinical clerkships. Regardless of which
rotation you are on, here is a list of things you need to do:
•• Before starting the rotation, be sure you have submitted
all the required forms and documents to the site (if this
applies to you). Make sure you are up-to-date with your
immunizations, TB-mask-fitting requirements, and any
other paperwork such as authorization for electronic
medical record access for the site. A quick and easy way
to look incompetent is to start a rotation and be unable
to do anything because you failed to make sure all the
prerotation requirements were fulfilled.
•• Before starting the rotation, read the course syllabus care
fully and know the objectives of the rotation, your respon
sibilities, your contact persons, and the evaluation/grad
ing system.
•• Always be early to everything, especially on the first day of
your rotation. Nothing looks worse than showing up late.
•• There will be a lot of information thrown at you on the first
day of a rotation. Arrive early, dress professionally, and
have a notebook to jot down important information such
as contact and pager numbers of the residents and the
location of various things in the hospital.
•• Maintain a professional demeanor at all times. Dress,
speak, and act the way you imagine a good doctor should.
Make sure your white coat is always clean and in good
condition.
•• Understand your responsibilities for pre-round activities
(helping the intern or junior resident; gather all informa
tion such as overnight events, vital, labs, etc.) and mak
ing rounds. During first few days on rotation, ask as many
questions as you need to completely learn about your
roles, responsibilities, and the expectations of the resi
dents and attendings.
•• Learn your daily schedules well. Memorize the times and
locations for pre-rounds, rounds, morning reports, and
conferences.
•• Quickly learn how to use the computer system effec
tively and how to extract important patient information.
Pay close attention to the particular lab values, drain out
puts, vitals, relevant history, etc. that the residents and
attendings find of particular importance and always have
these data ready to present. Each specialty and service has

a unique set of subjective and objective findings that are
particularly important to them.
•• Make sure that you know everything about your patients
and their conditions. Attending physicians vary in how
they conduct the rounds, their expectations, and their
teaching methods and preferences. But they all have one
thing in common—they expect you to know everything
about your patients.
•• Read up about each of your patients’ conditions. Rounds
are usually the time that your attendings will ask you ques
tions about the related medical issues for teaching and as
sessment purposes. It is your chance to shine. By reading
daily about each of the conditions you encounter, you will
maximize your learning experience during each rotation.
Even more impressive is reading up on the primary liter
ature and being able to cite seminal articles when giving
answers to questions.
•• Always interact with your patients in a professional
and respectful manner. Gather information in a timely
manner, wash your hands beforehand, introduce yourself
clearly, be patient and considerate in the physical exami
nation, end every interaction with an explanation of what
the impressions and plans are (when you have talked to
more senior team members and you are completely aware
of the plan of care), and inquire if the patient has any
questions. Once you are a resident, your responsibilities
grow exponentially and your time with patients shrinks.
As a medical student, you have the privilege of time. Use it
wisely to learn and understand your patients’ conditions.
•• When managing an angry or difficult patient, remain calm,
focused, and professional, and do not take their reaction
personally. Listen, reassure, and empathize with them.
•• Perform and write history and physicals (H&Ps). By now
you should have learned the basics of H&Ps; now is the
time to put your knowledge into practice. You should seize
any and every opportunity to practice performing and
writing up histories regardless of how painful and time
consuming it may be. The more you do it the better you
will be at it and the more time it will save once you are
in residency. H&Ps are something you will be doing on a
daily basis for the rest of your career; therefore, it is a criti
cal skill to develop. Different clerkships will have slightly
different emphases for their H&Ps, but the overall struc
ture will be the same. For example, medicine H&Ps are
more comprehensive and inclusive, while a surgical H&P
tends to be brief but precise. Learning the requirements
and expectations of each rotation’s H&P early on is impor
tant to success. You should go through your first few with
your residents to figure out exactly what they are looking
for. Writing H&Ps will also help you with your patient pres
entations, learning what is important to include and what
can be excluded.
•• Practice and become proficient in presenting your
patient. This is how medical professionals convey impor
tant patient information to other healthcare professionals
involved in the care and management of the patient. This
is a very important yet difficult task for almost all medi
cal students in the beginning. Do not be surprised to
see even residents who still have not become fully profi
cient at this. In short, you are telling the story of why your
patient is in the hospital and what the plan is for their
care. Your presentation must be done in a predictable,
concise, and precise manner. The format of an H&P is a
good place to start; however, only immediately pertinent
information should be included. You should practice
your presentations first by yourself and then with your
residents before presenting in front of your attendings.
As you become more and more proficient at presenting,
you will need less and less preparation.
•• Be a team player. The field of medicine has progressively

become a complex machine composed of individuals
working in teams to provide care for patients. It is only
when there is strong communication and collaboration
among every component of the machine that the highest-
quality patient care can be provided. Your job is to help
this machine function in any possible capacity. Always
ask and figure out ways to help. The more you do to help
without being asked, the more impressed your seniors will
be. It takes observation and a constantly analytical eye to
know how to help without being asked. Common tasks
include obtaining outside hospital records, following-up
on laboratory or imaging results, and gathering equip
ment for performing procedures. While some of the work
may be tedious and be viewed as “scut”, there is no job a
medical student is too good for. Your job is to learn how
every facet of the hospital works and what it is like to par
ticipate in every aspect of patient care. Every opportunity
is a learning opportunity.
•• Respect everyone on the team regardless of his or her
rank, even if they are unpleasant. In every field, there will
be difficult individuals that you will have to learn to deal
and work with effectively. In perspective, individuals han
dle the stress of the medical profession differently. Try to
understand that residents, who have many more respon
sibilities than you, are often tired, sleep deprived, and ex
hausted. However, no one, regardless of their rank, has the
right to disrespect, humiliate, or abuse anyone, and such
incidences should be reported to a senior team member,
the attending, or the site director.
•• Work well with your fellow medical students. While they
may be your competitors in certain respects, they are
your present and future colleagues. A student who does
not work well with others is a red flag, while students
whose residents and attendings see helping others are
viewed very favorably. Orthopedic surgery residencies
are small and the workload is vast. Residents either work
together to get all the work done, or drown. Residency
programs look for potential residents who will work well
with others, because just one faulty member can seriously
disrupt a team.
•• Come early and expect to leave only once all the work
is done. In order to expedite the pre-round and round
processes, try to get all the necessary patient information
the night before, and to be there before the residents.
Rather than focusing on what time you will be excused,
you should focus on getting all the work done in as timely
a fashion as possible so that everyone can leave on time.
•• Ask your senior resident(s) and attending physician for
a midrotation evaluation. Do not assume that you are
doing everything right and meeting all their expectations
without getting a formal evaluation. Rather, find out early
so you can improve on areas of weakness and make the
necessary improvements.
•• Prepare for the shelf examination and USMLE Step 2 ex
amination by reading as much in your spare time, on the
wards, and at home. Medical students should never be
idle. There is always more to learn, and residents and at
tendings expect medical students to be doing so. Since
the rotations are short, in general you do not have lots
of spare time to read. It is best to use one or at most two
review books in addition to a question source to prepare
you for the examinations. Ask students an year ahead or
those who have completed the rotation and done well
for their advice on books and tips. Start reading and prac
ticing questions early. Make it part of your daily routine.
THIRD-YEAR ORTHOPEDIC
SURGERY ELECTIVES
We devote an entire chapter to your fourth-year orthopedic
electives in Chapter 4 because of their importance. Third-year
electives are generally intro ductory-level orthopedic rota
tions mainly designed to introduce you to the specialty and
allow you to gain some experience. There are three things you
are expected to know on rotation: anatomy, anatomy, and
anatomy. Try to find out what procedures you are going to
scrub for the next day and read up on the relevant anatomy.
The rotation should be treated as a subinternship and you
should do anything and everything to learn about ortho
pedics and see if it is truly the field for you. Imagine yourself
as the resident and try to do as much as the resident does.
RESEARCH INVOLVEMENT
If you have not become involved in a research project yet,
your third year is an excellent time to do so. It is also the only
time you may have to initiate an orthopedics-related research
project before applying for residency. Some schools may have
an allocated research time during the third year, while other
schools may allow you to take a rotation off to do research.
Becoming involved in a research opportunity in your third
year means that you can carry the project into your fourth year
as well. Research involvement is also a fantastic way to make
connections and obtain letters of recommendation, which
are highly valued by residency selection committees. You will
often spend more time with your research mentor than any
other attending you work with on service. Please refer to
Chapter 9 for more information on this.
APPLICATION TO RESIDENCY PROGRAMS

Become familiar with the application process early in your
third year so that you can give yourself enough time to work
on your personal statements, and update your curriculum
vitae (CV). Please refer to Chapter 5 for more information
on this.
USMLE STEP 2 CLINICAL KNOWLEDGE

AND CLINICAL SKILLS EXAMINATIONS
Most students prefer to take the Step 2 clinical knowledge
(CK) examination right after the third year or in the first half
of the fourth year and many schools require that they do so.
Often students who have done very well on Step 1 will want
to delay taking Step 2 CK for fear of doing significantly worse
compared to their Step 1 score. You are not obligated to report
your Step 2 CK score if you take it, but some programs will ask
on interviews whether you have taken Step 2 CK and if so what
your score was. It should also be noted that more and more
programs are requiring applicants to take both examinations.
Therefore, it is important for you to look into the programs you
are interested in to find out their requirements. If you did not
do well on Step 1, Step 2 CK is a chance to redeem yourself.
Currently, the Step 2 clinical skills (CS) examination is
not a requirement for interviewing and ranking purposes.
You just need to pass this examination prior to starting your
intern year. Give yourself enough time for the reporting of
this examination as it may take up to 10–12 weeks for results
to be delivered.
REFERENCES
1. National Resident Matching Program. Data Release and
Director Survey. National Resident Matching Program, Wash
ington, DC; 2010.
2. Takayama H, Grinsell R, Brock D, et al. Is it appropriate to use
core clerkship grades in the selection of residents? Curr Surg.
2006;63(6):391-6.
4
Away Rotations and
Electives
Sean A Tabaie, Sean E Mazloom, Andrew Tsai
OBJECTIVES OF AWAY
ROTATIONS AND ELECTIVES
Orthopedic electives play an essential role in the residency
match. The overriding purpose electives of rotations, home
or away, in orthopedic surgery is to help candidates match
more successfully at competitive residency programs. We
have dedicated an entire chapter to this topic, as this is a
crucial component of the residency application process for
many reasons. Electives allow students to learn more about
orthopedic surgery, learn about specific programs, and
potentially significantly improve their chances of acceptance
to the institution at which they rotate. The competitive nature
of orthopedic residency has been well established. Though
a competitive curriculum vitae (CV) is integral to gaining
consideration by potential programs, special attention will
be given to rotating candidates. It has been demonstrated
numerous times that merely scoring above 250 on the
United States Medical Licensing Examination Step 1 and 2
examinations cannot save a candidate with poor social skills
or a bad attitude. Candidates with a less-than-competitive
CV can match once they demonstrate excellent drive, work

ethic, and communication skills. In addition to a high-
caliber rèsumè, home and away electives provide candidates
tremendous opportunities to gain a competitive edge. After
reading this chapter, you will have insight into the importance
of orthopedic electives and how can you get the maximum
benefit from your rotations.
Home vs away electives

Rotations at home and away institutions are both necessary,
but questions remain among applicants on the timing and
locations of these electives. Most agree the best place to
start is with an elective orthopedic rotation at your home
institution. Beginning at one’s home institution allows him or
her to concentrate on the rotation rather than finding one’s
way around a new hospital or new city. At this initial home
rotation, an applicant can get familiar with the orthopedic
surgery department and establish a rapport with the faculty
and residents. Opportunities for jumping onto research
projects or for strong letters of recommendation may surface
during the initial home elective. We advise candidates to
begin with a more general rotation, such as trauma, general
orthopedics, or a total joint service, which will allow for a
broad experience in the field. A general orthopedic service
will allow one to meet several different attending physicians,
many of whom may be on the admission committee later
during the application cycle. After doing a “home” orthopedic
elective, if a medical student decides orthopedic surgery is
the specialty to which he will apply, the student can then look
into elective rotations at other institutions. Away rotations
represent more opportunities for an applicant to improve his
chance to match in orthopedic surgery.
Away Rotations and Electives 35
When to Schedule the Electives

When planning your clinical rotations, it is important to
realize that electives do not have to begin in the fourth year of
medical school. Knowing this, a home rotation can be started
as early as the beginning of the third year. All medical schools
have required core rotations (internal medicine, pediatrics,
obstetrics/gynecology, etc). Depending on the lengths of
these core rotations and the option to delay some into fourth
year, you may be able to find time during your third year for an
orthopedic rotation (assuming the appropriate prerequisites
are complete). If you are unsure whether orthopedic surgery
is the specialty to which you will apply, scheduling the home
rotation early will allow you to make changes in your schedule
appropriately if you change your mind.
Once again, the home rotation is best done before any
away rotations. First, ensure that you have met all necessary
prerequisites to begin the rotation—many schools require
general surgery to be done prior to a surgical sub-specialty
rotation. Next, plan when your home rotation will take place.
Rarely do third-year students rotate through orthopedics
as an elective at the start of the academic year. As such,
you would stand out. Being noticed as a hard working and
capable third-year student can be a huge asset to gaining
respect, favor, and letters. Standing out as a third-year student
on an orthopedic rotation, however, is no easy feat. You are
competing with fourth-year students who have had a full year
of clinical experience already and many have already proven
themselves through prior research projects and rotations.
Make sure to read ahead and thoroughly learn the basics.
A third-year student who pleasantly surprises the attending
by systematically evaluating a basic radiograph can easily
outshine a fourth-year student who may be average for their
class despite the difference in knowledge base. Disproving the
stereotype of the inexperienced third-year medical student
make you memorable in the minds of your attendings.
Rotations in the middle of the academic year also have

their benefits. Between October and March, fewer students
rotate through the elective specialties, and interview season
runs through the early portion of this period for senior
medical students. Fewer students mean a greater opportunity
to be noticed and less comp etition for procedures. The
residents have also gained several months of experience by
this time and may be more amenable to having you take a stab
at a reduction or compartment pressure check. Do not allow
the mid-year lull to kill your enthusiasm and motivation.
Taking orthopedics as an elective means having no shelf
exam to study for and fewer outside distractions. Know that
the residents and attending are aware of this so use your extra
time to show more effort. You can separate yourself from
other rotators by putting in extra hours, taking extra calls, or
rounding on weekends.
Late in the academic year (April/May), there is a second
spike in elective rotators at the home program. By now, most
third-year students will have completed general surgery and
many other core rotations, you will be more versed in basic
patient care. The beginning of summer is also the beginning
of the busy trauma season. Though there is more competition
from other students, there is also more case volume. It is
during the busy time in the hospital when you can be most
useful to the service as a third-year student. The residents
are also nearing the end of another full year of experience
and many, even the interns, have become more comfortable
on the teaching end. Take the initiative to ask for procedures
such as reductions, splints, and setting up traction beds. The
residents have also become more efficient and have more
time to correct you where you err. They often need reminding,
because at this point it is simply easier and quicker for them to
perform small procedures themselves.
Overall, begin your rotations as early as you can and
begin at home. Start with the general specialties—pediatrics,
general orthopedics, or trauma surgery—then build on it. If
you make a late decision to pursue orthopedic surgery, speak
with your student affairs staff about modifying your schedule
to accommodate home and away rotations in a way that will
maximize your chance of success. Find out what your medical
school policy is on elective rotations and if core rotations can
be postponed until your fourth year. Even if a general policy
on rotations prevents you from taking a rotation when you
want, a quick stop at the student affairs office can often allow
you to change your schedule to in a more favorable way.
Study the basic terms, splints, fracture patterns, and their
management, which you may build upon later in residency. To
learn the basics, Netter’s Concise Orthopedic Anatomy is an
excellent choice. To get a better handle on trauma, fractures,
and splinting, read Handbook of Fractures (Egol, Koval, and
Zuckerman). Do not forget the basic Internet search engines
and resources such as Orthobullets and Wheeless Online.
BENEFITS OF AWAY ROTATIONS

After the home rotation, any outside program is considered
an away rotation, even if it is two miles away. Your home
institution will probably have encouraged you to consider
their program after you rotated with them. You have probably
heard ad nauseum about their advantages and perks. Away
rotations help put everything into perspective and allow you
to evaluate your home school compared to other national
recognized programs. Very similar to casting calls and
movie auditions, you are being closely evaluated at almost
all times during these rotations. An away elective rotation
should be considered a month-long interview. You will have
many opportunities during the rotation to demonstrate your
skills and assure the program director that you are the right
candidate for the job. Getting invited back for an interview
after an away rotation is common at most programs, and any
additional interviews will increase your chance of getting
into a residency program. By getting to know the faculty and

senior residents who may interview you later, you can further
improve your chances of acceptance at that program.
Another goal of the applicant rotating at an away
program is to get excellent letters of recommendation. If your
home program and small and lacks faculty with nationally
recognized surgeons, rotating at a top notch hospital will
allow you to meet leaders in the field whose letters may carry
significant weight. Even if you decide you would not like to
end up as a resident at a place you rotate, be gracious, show
interest, and get a letter from the appropriate faculty. When
applying to residency, programs will expect a letter from
institutions where you did an elective rotation. Not being able
to produce a sparkling letter of recommendation from your
away rotation can put you in an awkward position later on.
While you work hard to impress the residents and
attendings during your away rotations, remember to evaluate
them as well. It is important to get a feel for what it would be
like as a resident of the program. You will notice the differences
between programs immediately. Some programs are rigidly
hierarchical, whereas other programs breed autonomy or
teamwork. Most programs are in the middle. No matter where
the program falls on the spectrum, every resident and every
student in every year has core responsibilities and skills which
must be learned. On top of this, there should be a natural
mentorship by senior-year residents to junior-year residents.
Do the chiefs teach well in the operating room to the juniors or
do they simply take the most interesting cases for themselves
and make the juniors run the floors and stop in for the admit
orders? Take special care to observe the second, third, and
fourth year residents as they may be your seniors and chiefs
when you step up the ladder. The best chiefs during your
rotation do not guarantee excellent chiefs in the following
year. Observe their teaching methods and scrutinize their
morning, evening, and attending rounds for social interplay.
Question the interns to see if they feel they are learning
enough to be ready for their second year. Question the chiefs
to see if they feel ready for a fellowship or an actual job. Even
question the attendings to see if they are satisfied enough
with their graduating class to hire them as attendings in the
future. All of this speaks to the experience you will receive
in the program and how happy you will be within this team
environment.
There are many benefits to away rotations, as has been
outlined above. The away rotation is a chance for a potential
program to evaluate you, and for you to do the same. Your goal
during any orthopedic elective should be to leave a positive,
lasting impression on all the residents and attendings you
work with as they may have an influence in your acceptance
in one way or another.
Many programs pick their future residents from their
pool of rotating medical students, and many medical students
find their future residency training programs based on what
they see during away rotations. Keep these thoughts in mind
as you set out to do your away rotations.
WHERE TO DO AWAY ROTATIONS
There are numerous opinions on where to do away rotations.

Some believe that rotating through a program that you want to
match with is beneficial, while others believe it is a detriment
and can only hurt you. We do not believe either is an absolute,
and any candidate has the potential to help or hurt his chances
of getting into residency during an away rotation.
An away rotation at one’s dream program can help the
competitive, energetic, hardworking student’s chance of
matching into that particular program. It is also a time when
some students realize a particular program may not be a great
match. Most students will enjoy their away rotations, however,
and ingratiating one’s self to the attendings and residents will
make him or her more memorable when the department sits

down to rank their applicants. Many residency programs will
want to know that a student really wants to be there. If you
truly do enjoy a program and want to match there, you should
let them know during your rotation.
Despite all the benefits of doing an away rotation at a
program you wish to join later, there are some risks involved
in remembering that surgeons tend to be high-achieving
individuals who sometimes have strong personalities, if you
clash with any of the residents, attendings, or nurses and
physician assistants (PAs), you may harm your chances of
matching there. Always be conscious that the residents and
attendings you work with are judging you and talking about
you. Residents and department PAs are constantly asked by
attendings about the quality of the rotating medical students.
Never be rude to anyone and try your hardest to work hard
and help other team members. Words and rumors get around
quickly. If you are aware that you are socially awkward, you
may want to practice your skills at another program prior
to trying your luck at your dream program. Develop a firm
handshake and eye contact so you can make a good first
impression with everyone you meet. You know your own
strengths better than anyone and can better judge where to go
than anyone. One negative impression is all it takes to offset
all your hard work and kill your chances at matching into that
residency program.
If you do not have any particular programs in mind
to which you want to apply for residency, ask fourth year
medical students, residents, or faculty for recommendations.
Other medical students may have recent experiences at other
schools that will help you decide where to go. Learning about
the strengths and weaknesses of different residency programs
will help you formulate a list of possible schools to which you
could rotate. Residents and interns at your home program
may also be able to give good recommendations of where
to apply for away rotations, since they may come from other
areas of the county and have insight you do not. Also ask your
home program’s residency director and department chair
about their advice. Orthopedics is a tight knit community
of individuals who have worked with other department
chairs and program directors in some way. Your local faculty
with their own unique experiences during residency and
fellowships and consequent networking capabilities may also
provide invaluable resources.
Try to keep an open mind and consider different pro
grams. If you have a particular interest, then rotate through
those subspecialties after you have already learned the basics.
Fill holes in your understanding of the field and use away
rotations as a tool to do so. An away rotation is a gold mine for
gaining experience of all kinds.
WHEN TO DO AWAY ROTATIONS

Many medical schools will not allow students to do away
rotations until they are in their fourth year. Because of this
small window of time, research and schedule your away
rotations early. Away rotations in orthopedics fill up quickly,
and the most coveted months to do them in are July and
August.
A benefit of doing rotations earlier (July through early
September) is the opportunity for getting letters of recomm
endation required for your residency application. If you do a
rotation very late in the fall or in the winter, the strong letter
of recommendation you worked so hard for may not arrive at
a program director’s desk until all interview invitations have
been handed out. The downfall of doing rotations early is that
you will have to compete against more rotators for a rotation
slot in this time frame and the attention and preference of the
attendings and residents.
The benefits of later rotations (late September through
November) are that they fill up more slowly and there tends to
be slightly less competition for good cases, call, and attention

from residents. Another seldom-recognized benefit is that a
candidate at an interview may be remembered more easily than
one who rotated six months or longer prior to the interview.
Being recognized at an interview is a good ice-breaker and
can allow you to re-iterate your interest in that program. There
are some drawbacks or dangers in late rotations, though. If
rotating through a program very late, it may be the case that
the program has already given out all their interview slots.
Since one of the main benefits of doing an away rotation is
getting an interview, your effort may not be so beneficial later
in the game. However, if you are outstanding and can impress
the program, you may be granted a special, onsite interview
during your rotation, which would be a tremendous boost to
your chances of matching into orthopedics. Another danger
of rotating very late is the possibility of having an interview
overlap with your away rotation. It can be somewhat awkward
to request time off from an away rotation to interview at
another program.
So, schedule your away rotations carefully and have a
plan for when you do which rotations. The correct timing of
your away rotations could make a big difference in the benefit
you get out of it. Away rotations take a large amount of effort,
time, and sometimes money, so pick your rotations wisely.
HOW MANY AWAY ROTATIONS?

Candidates should plan on doing multiple rotations as their
schedule, medical school, and finances allow. The common
number of rotations is three—one home rotation and two
away. Many students may go overboard, but in general it
is not recommended to do more than three orthopaedic
rotations. These rotations are very intensive in the workload,
hours, and training, and are to some extent stressful. Many
institutions may require taking overnight call every three or
four nights and working long hours on other days. Therefore,
you may be exhausted and not at your optimal energy level
leading to average performance by the time you get to your
third or fourth rotation. You should be concerned with your
performance level and quality of work rather than the number
of rotations you do. Doing only two orthopedic electives and
hitting them out of the park is much better than putting forth
a mediocre effort at three or four away electives.
Another thing to keep in mind is that on away rotations,
you are also away from those faculty members with whom you
are doing research. If the research study you are involved in is
something that can be done remotely, remember to get the
appropriate online clearance and remote access so you are
not hindered by being away. If a project cannot be worked on
remotely, then be sure you have enough time to complete it.
LETTERS OF RECOMMENDATION
On each rotation, both at home and away, there is the
opportunity to ask for letters of recommendation. If you are
performing research with faculty, the opportunity is even
greater. It is important that the attending knows you well prior
to asking for a letter. It reflects poorly on your application
to have a so-so letter from someone who clearly does not
know you very well. Letters from a chair person or program
director typically hold more weight than those from unknown
attendings; however, if another attending knows you better
and can write you a phenomenal letter, he or she is the best
choice. If you are interested in a particular field, talk with
that attending about it. Why did they choose hand, joint, or
pediatrics? What should you do to expand your knowledge as
a student and prepare for those fields as a resident? The level
of your interest in that attending’s field is directly proportional
to their level of interest in you. And if you do not have an
interest in a particular area yet, then focus on the attending
you mesh with best.
After getting affirmation from letter writers that they

will write you a letter, make sure to follow up. They are, after
all, full-time orthopedic surgeons and have busy schedules.
Remind them politely and leave messages through their
assistants if their letters do not arrive in a reasonable amount
of time. Be sure to ask for the letter at least one month before
it is due. For more information on letters of recommendation,
please refer to Chapter 5.
WHERE TO STAY
Traveling to an away rotation can be costly. In addition to
finding housing, most students continue to pay rent where
they were living. There are many options for housing during
the time of your away rotation. Many medical schools can
offer financial assistance in the form of small loans to help
with the cost of applying to residency or rotating away; be sure
to look around if finances are a concern.
The first place to look for housing is the website of the
residency program through which you will be rotating. Many
have a page dedicated to helping away medical students either
through local listings or even on-campus housing. Moving to
a new city for a few weeks can be intimidating, but many other
students have done it before you.
Many students sublet an apartment or find temporary
housing through venues such as Craigslist or other Internet
sites, and others stay with friends or family who live in the
area. Another good way to find housing is through the medical
school alumni network, which is safer, cheaper, or free.
Medical schools have various ways of putting their alumni
in touch with their current students. For example, alumni
are asked to volunteer to be on a housing list, which is kept
at student affairs. During away rotations, students are able
to search for alumni living near their site and find temporary
housing for cheap, if not free, rates. It is also an excellent way
to get to know that physician and perhaps be introduced and
recommended to the orthopedics program through them. If
this particular program is not available at your medical school,
often the office of student affairs may have a list of alumni that
have matched. This list is available to any who have interest
in that field and need mentorship. It may be worth your time
to look at the list and see if there are any suitable alumni who
may have an extra room.
Using a local realtor in the area to find a sublet is also
an option. They are often hired through the landlord to find
renters. Keep in mind that finder’s fees are usually covered by
the landlord, not you. If any realtor requests a fee from you up
front, ask what the cost structure is for their reimbursement in
writing. If you are, indeed, to be paying the realtor’s fee, don’t
be afraid to negotiate, mentioning you are only planning to
stay a few weeks.
If you’re staying with a friend, make sure they understand
the effort you must put forth during the rotation and that
your schedule may not best fit their social life. Yes, it is an
opportunity to see them and socialize; however, be sure to do
so without affecting your performance. This is your month-
long interview chance. As previously stated, your energy and
interest in the specialty and the program can make or break
you at any site, home or away. Saving a few hundred dollars
on housing may turn out to be a losing proposition if you end
up doing poorly during the rotation.
SUMMARY
Here are our recommendations for success in your fourth-
year orthopedic elective rotations, which are similar in many
aspects to our recommendations for success in your third-
year clinical clerkship rotations.
•• Apply for these electives early.
•• After a full investigation of your possibilities, carefully
select your orthopedic rotations.
•• Look into and plan for your housing options early. Paying
a little more for more convenience, safety, and privacy
may be very well worth it.
•• Always get to the hospital early, especially on your first
day.
•• Learn about your schedule, meetings and conferences,
and know the times and locations of your meetings in
advance. Find out your resident’s contact information on
the first day.
•• Understand your responsibilities and everyone’s expec
tations in the first few days.
•• Learn about the electronic medical recording system of
each hospital early.
•• Always be enthusiastic, professional, and pleasant.
•• Do not ask for breaks or mealtime (unless you absolutely
have to), but always have snacks or small meals with you.
•• Arrive earlier than your residents for pre-rounds and stay
as late as everyone else in your team.
•• Know your patients well; read and learn about their
conditions, the related anatomy, and both the medical
and surgical managements.
•• Be a team player at all times. Stay and work closely with
your residents and always be accessible to help them with
the floor tasks.
•• Meet and familiarize yourself with each patient prior to
going to the operating room.
•• Before leaving the hospital, have the list of the next day’s
procedures so that you can read and prepare before
scrubbing for those cases.
•• Take calls with your residents. This way you will learn
more about the floor responsibilities and management,
help with overnight trauma cases, and get a better feeling
of the residents’ lifestyle and hours during residency. This
is also a great time for your residents to get to know you.
•• Attend all the conferences and lectures sponsored by the
orthopedic department for the residents or students even
if they are optional.
•• Read and review your anatomy in your spare time. Refer
to the list of our recommended orthopedic and anatomy
books to read during your third and fourth years of
medical school.
•• Be nice, respectful, and treat everyone the way you would
like to be treated. Be friendly to everyone, as residents will
talk to each other about every applicant.
•• If possible, try to work mainly with one or two attending
physicians during your rotation so that they have the
chance to get to know you well and can write you a strong
personal letter.
•• Treat and work with the other medical students in the team
as your colleagues. You can help each other throughout
the rotation, study, and make the rotation more fun for
each other. Remember that orthopedic surgery is a small
field, and you will be running into the same residents
and other candidates you meet during your rotations or
interviews at some point. Instead of competing with other
students, make friends with them, as these may become
life-long friendships.
•• Offer to give a presentation on any orthopedics-related
topic. Make sure that you spend enough time on preparing
an impressive and well-informed presentation. Giving an
outstanding presentation can help to make you stand out.
•• In the last week of your rotation, ask for letters of
recommendation from the attending physicians you
worked closely with. Make sure to provide them with your
CV or personal statement, filled-out request form, a pre-
addressed, stamped envelope, and any other materials
before finishing your rotation.
Elective rotations in orthopedic surgery are a necessity
that can be an asset if you use them well. Start your away
electives early if you can, and make the best of every rotation.
This is a vastly diversified field with no shortage of excellent
applications but a very limited number of residency positions.
Getting to know the field and being known as a phenomenal,
hardworking student are worthwhile goals to strive for at
every rotation. It will land you the report, the letters, and the
endorsements of those who will judge you.
5
The Application
Process
Sean E Mazloom
Acceptance into a competitive residency such as orthopedics

may require months, if not years, of persistent endeavor and
strategic planning. To help you along this path, this chapter
focuses on orthopedic residency application process and
provides an easy-to-follow and step-by-step guide and time
line for this process. This chapter further discusses the key
factors to success in each stage from undergraduate years
through residency application. Paying attention to important
dates and deadlines throughout this process is crucial to
avoid any delays or missing opportunities. Make sure to read
all other informative chapters of this book as each provides
an in-depth review of many important topics and factors
involved in this process.
UNDERGRADUATE YEARS
For those applicants determined to pursue medicine, the
main focus during the undergraduate years should be to
get honors in all their courses and to do well on the Medical
College Admission Test (MCAT). Getting into medical school
could be another book or chapter unto itself, but suffice to say,
it is a necessary pre-requisite for admission into residency.
Applicants’ activities and preparation for medical school

entrance can give them a leg-up during residency applications
if planned well and in advance.
Extracurricular activities, such as volunteering, comm
unity service, and basic science research are all areas in which
applicants may participate early on in undergraduate years.
Students may also contact academic orthopedic programs for
research opportunities, as many researchers and physicians
welcome interested undergraduate students. You may also
contact local orthopedic surgeons, perhaps through your
school, to find out about shadowing opportunities in clinic or
operating room. Early involvement in research and shadowing
opportunities allows applicants to learn more about different
fields and explore their own interests, while strengthening
their applications.
First Year of Medical School

Starting medical school brings about new challenges for many
students due to large volume of study material with too little
allocated time to master all the subjects! However, similar to
many other stages of life, early planning and hard work is the
key to success in medical school. Your primary goal during
the first two years should be to learn as much and to achieve
honors in all your courses! Remember that selection to Alpha
Omega Alpha (AOA) is primarily based on your performance
in medical school courses.
The first year of medical school is also a great time to
become familiarized with different medical fields through
volunteering and shadowing opportunities. Shadowing ortho
pedic surgeons allows you to explore the field and its scope of
practice early on in medical school. The sooner you become
interested in a particular medical field during medical school,
the more time you will have for planning and preparation.
Additionally, getting involved in a research project in the first
year of medical school is very beneficial, especially if you have
The Application Process 51
little research experience in the past. The summer between
the first and second year of medical school is unstructured at
most schools, so it is a great time to initiate a research project
in a field of interest such as orthopedics.
Second Year of Medical School

Similar to first year, academic success should be applicants’
primary goal during the second year. However, the amount
of material that needs to be mastered is greater than the first
year, and you still need to review your first-year subjects to
prepare for the United States Medical Licensing Examination
(USMLE) Step 1. Therefore, you should not allow excessive
extracurricular activities and research to overshadow your
academic priorities. Please refer to chapter 2 for more
information on how to do well in the first two years of medical
school and the USMLE Step 1 examination.
Third Year of Medical School

Responsibilities and tasks in the third year greatly differ from
those during the first two years, but again your goals should
be to learn as much and to get as many honors as possible
in your clinical clerkships. Please refer to chapter 3 for more
information on keys to success in the third year. If your school
offers orthopedic rotations in the third year, take advantage of
this great opportunity to further explore the field. These early
rotations allow applicants to learn more about orthopedics
and to prepare for the fourth-year orthopedic electives.
Uncertainty about choosing specialty of interest may persists
well into fourth year of medical school among students;
however, elective rotations in different specialties, if possible,
can greatly help with this important decision.
In the second half of this year, applicants should look into
and apply for fourth-year orthopedic “away electives”. These
rotations, also called “acting internship” or “subinternship,”
are mainly available through the Visiting Student Application
Service (VSAS). More information on VSAS is available

through the AAMC website. Third year is also the time
you should begin working on your residency application.
Especially toward the tail end of the year, you should start
preparing your curriculum vitae (CV) and your personal
statement (PS). Also remember to register for the USMLE
Step 2 Clinical Knowledge (CK) and Clinical Skills (CS) exams
sooner rather than later.
Fourth Year of Medical School

As previously mentioned in chapter 4, applicants should
preferably begin this year with orthopedic electives. Try to
do two or three electives, including one at your home insti
tution program. Away rotations are important part of your
application as they can lead to residency interviews at other
institutions and demonstrate your willingness to move to
other geographical locations. Letters of recommendation
should preferably be obtained from all institutions where
you undertake clinical rotations. Make sure that you have
your letters of recommendations ready by October 1. Register
for Electronic Residency Application Service (ERAS) and
National Resident Matching Program (NRMP), and complete
your application and personal statement early.
ELECTRONIC RESIDENCY
APPLICATION SERVICE
ERAS is an online service that transmits residency applica
tions, letters of recommendation (LoRs), medical student
performance evaluations (MSPEs), medical school trans
cripts, USMLE transcripts, COMLEX transcripts, and other
supporting credentials from you and your designated dean’s
office to residency programs. ERAS consists of MyERAS
(the website where you create your residency application);
the Dean’s Office Workstation (DWS), software used by
the designated dean’s office/medical schools; the Program
Director’s Workstation (PDWS), software used by the
residency program(s); and the ERAS Post Office. The dean’s
office of your medical school will issue you a token, or an
alphanumeric code, used to register and access MyERAS in
late June. After registration, you will access MyERAS using
the AAMC identification that was given to you as the final
step of your registration process along with your self-created
password. Beginning July 1, all applicants may use MyERAS
to begin completing their application, identifying programs
in which they are interested, and creating and assigning
supporting documents.
Applicants applying to ACGME-accredited resi dency
programs (September application cycle) may apply to these
programs beginning September 15, while applicants applying
to AOA-accredited residency programs (DO programs) may
apply to these programs beginning July 1. A notification is sent
to your dean’s office when you use your token and when you
apply to programs. Your dean’s office will attach your medical
school transcript, LoRs, a photograph that you provide, and
MSPE (if available) to an electronic file designated for you
on the Dean’s Office Workstation (DWS). The files are then
transmitted from your designated dean’s office to the ERAS
PostOffice and placed in the mailboxes of the programs to
which you applied. Using the Program Director’s Workstation
(PDWS), program staff can download applications and the
supporting documents. Using this system, the admission
committee members may print, review, and evaluate appli
cations prior to granting interviews.
For 2014 cycle, ERAS fees are $92 for the first 10 programs
per specialty, $9 for each of the next ten programs, $15 for
programs 21-30, and $26 for each additional program. In
addition, the NBME fee for transmitting USMLE transcripts
is $70, regardless of the number of transcripts requested. The
National Board of Osteopathic Medical Examiners (NBOME)
fee for transmitting the COMLEX transcripts is also $70,

regardless of the number of transcripts requested.
Steps in the ERAS Process
Step 1 Learn about programs and contact them for

information.
Step 2 Obtain MyERAS token and User Guide.
Step 3 Register with MyERAS online.
Step 4 Create your profile.
Step 5 Create your MyERAS application.
Step 6 Create your personal statement and request
supporting documents.
Step 7 Select programs.
Step 8 Assign documents to programs.
Step 9 Certify and transmit your application.
Step 10 Check the status of your application using the
Applicant Document Tracking System (ADTS),
check your email, and monitor the Message
Center for information from programs.
Step 11 Select and apply to new programs, update
your documents, and track their delivery, as
necessary.
Step 12 Keep your profile up-to-date.
Step 13 Register for your applicable match.
PERSONAL STATEMENTS
Compared to the medical school personal statement (PS),

the residency PS plays a smaller role in the selection process.
However, you still need to follow certain guidelines to make
this part of your application effective and applicable to the
evaluator. You may create more than one PS, though only one
PS may be assigned and sent to each individual program. Each
PS is limited to 28,000 characters (approximately 8 pages),
however, it is highly recommended that you limit your PS to
approximately one single-spaced page. For those individuals
on the selection committee who have to filter through
hundreds of applications, reading more than one page of a
PS can be a daunting task. Your PS gives you an opportunity
to express your reasons for choosing orthopedic surgery and
also allows you to elaborate on any major academic shortfalls,
weaknesses in your application, obstacles, or any personal
challenges you encountered in medical school. However, be
careful not to spend a major portion of your PS dwelling on
your shortfalls and weaknesses as this may play against you.
Also, make sure your PS uses correct grammar and syntax
and is completely free of spelling errors. Additionally, some
programs may require additional information that is not
included in your transcript or MyERAS application, so you
may include this information in your PS and submit it to that
specific program.
You will be able to edit any PS that has not been trans
mitted to a program. But once you have transmitted a PS to a
program, it becomes locked. If you decide to modify your PS,
you will need to create and submit a newly created version.
To better identify your PSs, if you have created more than one
letter, try to be descriptive in the title of your PS. Programs will
not have access to information regarding the number or title
of your PSs.
LETTERS OF RECOMMENDATIONS (LoRs)

We have discussed LoRs throughout this book; how ever,
secondary to the importance of this topic, I decided to
include a section on letters here. It has been well recognized
that strong letters can play significant roles in the selection
process! However, an essential question in the mind of many
applicants is how to get exceptional letters. Simply put, the
longer and more closely you work with someone, he or she
will better get to know you, which more likely results in a
stronger and more personalized letter. However, do not

discount your chances of obtaining a great LoR when you
work with someone even for a month during your fourth-
year orthopedic electives. Many attending physicians are
accustomed to writing letters for students they have worked
with briefly, and they know how to evaluate students even
in a few weeks, if not days! But if possible, you should try to
work closely with a selected number of orthopedic attending
physicians on a long-term basis prior to requesting for letters.
Do not be afraid to ask the letter writer if he or she knows you
well enough in order to write you a strong and personal letter.
If your letter-writer indicates he or she is not quite familiar
or comfortable writing a letter for you, be very wary about
sending such a letter to programs! Most orthopedic residency
programs only require letters from orthopedic surgeons;
however, a few programs may request nonorthopedics or
non-surgical letters, so it is beneficial to request in advance
and have such letters available.
The Letters of Recommendation tab in MyEras allows
you to create a list of people who will write letters on your
behalf. Make sure to stay in contact with your dean’s office for
any special processing instructions and to keep track of which
letters are yet to be received. Along with the letter itself, you
must indicate whether you waive your right to see the LoR. We
encourage you to request “closed letters” by waiving your right
to see them. You may request and then create an unlimited
number of LoRs in MyEras; however, no more than four letters
may be assigned and sent to any individual program.
RESIDENCY APPLICANTS
TIMELINE: ERAS 2014
Please be advised that the dates mentioned below are subject to

change during each application cycle.
Third Year of Medical School

Early in the Year
•• Apply for your third-year orthopedic electives as early as
your school allows.
•• Find an orthopedic adviser/mentor if you do not have one
yet.
•• Start searching for “away electives”, and by January/
February finalize your decision about where you want to
do these electives, and apply early through VSAS.
Mid-late June
•• MyERAS User Guide becomes available.

•• Schools begin to generate and distribute MyERAS tokens
to applicants.
Fourth Year of Medical School

July 1
•• MyERAS website opens to applicants to begin working on
their applications.
•• ERAS Support Services at ECFMG will begin generating
and distributing tokens to IMGs.
July 15
•• Applicants in osteopathic programs may begin selecting
and applying for osteopathic training only.
•• Applicants in osteopathic training programs may begin
contacting the ERAS PostOffice to download application
files.
September 15
•• Applicants may begin applying to ACGME accredited
programs.
•• ACGME-accredited programs may begin contacting the

ERAS PostOffice to download application files.
•• Applicants may also begin registering for NRMP.
October 1
•• MD applicants’ MSPEs are released to ACGME accredited
and American Osteopathic Association (AOA)-accredited
programs.
November 30
•• NRMP registration deadline. ($50 late fee afterward).
December
•• Military Match
January
•• Urology and ophthalmology match
January 15
•• Applicants and programs may start entering their rank
order lists.
February 26
•• Rank order list deadline and also deadline to withdraw
from the main residency match!
February
•• Osteopathic Match results become available
March
•• NRMP Main Residency Match results become available
•• SOAP
May 31
•• ERAS PostOffice will close to prepare for the next season.
6
Interviews and
Preparations
Sean E Mazloom, Troy Mounts
In this chapter, we provide you with essential information on

how to prepare for this last but highly anticipated part of the
residency application process. You have worked very hard for
the past couple of the years and now you are, waiting for the
interviews. Compared to most other programs, orthopedic
surgery programs will contact applicants late for interviews,
and the interviews are offered in the later months of interview
season. The earliest you will hear from programs regarding
interview offers would be late September. However, do not
panic if you have not received any interviews even by mid-
November. Most programs start to offer interviews in late
October and November for the months of November-January.
You may even receive interview offers as late as January,
especially if you were placed in the program’s waiting list.
Many programs offer only two interview dates, with a few
offering as many as three. However, by the time you contact
the co-ordinator for scheduling your interview, only one day
may be available. Do not be surprised to see overlap among
program interview dates as December and January are very
popular months for orthopedic surgery interviews. There
will be times when you have to choose between two or more
interview offers held on the same day.
Orthopedic surgery programs around the country over

the past few years have received some of the largest number
of applications per available slots. Many programs receive
over 600 applications for their few available positions. In
return, the programs are sent anywhere from 40 to over 150
interview invitations. Invitations were selected based on
merit and likelihood that the applicant would be a good fit to
their program.
Receiving an interview offer is a big foot in the door.
The next step is up to both the applicant and the program.
The intent of the interview is simply to put a face on your
application and see who you are in person. For the most part,
all of the applicants interviewing for competitive specialties
like orthopedics look very similar on paper with few subtle
differences, so this is your time to set yourself apart. It is also
your time to evaluate the program first-hand and to see if you
like the characteristics and culture of each program along with
the personalities of the residents and the faculty members.
Remember that residency is at least half a decade long, and
the last thing you want is to work with people you cannot get
along with.
Simply put, the interview process is a chance to put a face
with an application and decide if you are someone to which
the program would like to devote 5–6 years of training. It is
an opportunity for the faculty and the residents to see if the
applicant would be a good fit from a personality standpoint
for the program. Typically, programs look at the applicants’
professionalism and ability to interact well with their peers
and the faculty. Interviews are only offered to applicants who
on paper have the necessary qualities and achievements
to perform well as orthopedic residents. The interview can
secure you the spot that you need or it can send you home
empty handed. Therefore, you need to make sure to make the
most out of this exceptional opportunity. You may think of
your interview as speed dating. Some questions asked about
Interviews and Preparations 61
your research or studies are really just to get you talking,
hear your responses, and see your reactions. If you see a nice
segue, seize the opportunity and tell an interesting story about
yourself. Our advice for candidates is to be honest, polite, and
enthusiastic.
HOW MANY INTERVIEWS TO GO TO?
In general, considering the competitiveness of orthopedic

surgery, we strongly encourage you to apply to a reasonable
number of programs, and to attend as many interviews
as possible. On the other hand, do not apply or go to the
interviews at places where you absolutely have no interest.
In general, well-qualified applicants who apply broadly and
to a reasonable number of programs will receive the most
number of interviews. Statistically speaking, applicants
need about 9–10 interviews to secure a spot in orthopedic
residency. However, the number of interviews itself is not a
guarantee and cannot compensate for lack of social skills and
poor interview performance.
Some programs may provide specific information about
interviews on their website. You may find information on
programs’ outline, goals, rotations, call schedules, and their
current residents. The website usually has links to things to do
around the city where the program is located. It is important
to use these resources to both know about the program and
the city in which it is located. Programs like to see applicants
who have vested interest in what they have to offer. In short,
they want to know the reasons why you want to be there.
Make sure that you reply to interview offers quickly
as programs offer limited interview slots and dates. Also
make sure to pay attention to and follow the instructions for
scheduling your appointment as mentioned in the e-mail. If
you are asked to call to schedule your interview, then call the
coordinator and do not simply send an e-mail, as that person
might not check his/her e-mails frequently. And remember

that whomever you talk to, no matter what their role is (i.e.
secretary, etc.), they are an integral part of the family/
department to which you are applying. It should therefore
go without saying that you should be cordial and respect
everyone along the way.
BOOKING YOUR FLIGHTS AND HOTELS
The interview trip costs can be a big burden on the applicants,

but you may save some money by booking your flights or
hotels early. It is recommended that you book your flights and
plan for your interview trip sooner rather than later. However,
sometimes you may prefer to postpone purchasing your flights
until you are offered more interviews. The close proximity of
some interview dates to each other may make it desirable
to travel from one interview location to another directly.
It would be ideal to have interviews from the programs in the
same city or region right next to each other; however, that is
usually not the case. If you have received several interviews in
the same city or region, you may try contacting the programs
to see if you can be granted interviews around the same day.
Most programs, however, have pre-set interview days and
this may not be feasible. Here are some popular websites
among students for booking discounted flights and hotels
prices: http://www.studentuniverse.com/, http://www.price
line.com/ (you can take advantage of their option to bid and
name your own prices).
INTERVIEW PREPARATION
Do not take this opportunity lightly; be as prepared as
possible for each interview. In general, residency interviews
are very similar to job interviews as opposed to medical
school interviews. You are interviewed for an important and
crucial position, which you will accept and hold for at least
another 5 years. The programs need to know that you are the
right candidate for this critical position, which places you in
charge of patient’s lives. Although the residency interviews in
essence are very similar among different residency programs,
orthopedic residency interviews occasionally can be intense,
intimidating, or stressful. Knowing this prior to the interview
day, you can mentally prepare yourself and reduce your
anxiety level.
Programs have received much information about you
on paper; they are interested in you and now they want to
meet you in person. During most of the residency training,
you will spend more time in the hospital and with other
residents than perhaps at home with your family. Therefore,
it is imperative for the programs to make sure that they rank
the most qualified applicants who are also the best fit for their
program. Thus, many programs will make sure that as many
physicians and residents meet and interview you as possible.
In general, three or four rooms are set up with anywhere
from 5 to 10 people interviewing you. A few programs may
maximize the exposure by having as many as 15 interviewers
to meet you, some doing so as panels and some, as traditional
one-on-one interviews. The program’s goal for the interview
is to learn more about your personality and interaction with
others, academic achievements, research activities, and
sometimes your critical thinking under pressure. You should
stay calm and relaxed; be honest and energetic throughout
the interview.
Know about yourself. As ironic as this may sound, many
times we meet applicants who are not very familiar with their
own applications. You should know everything in detail about
what you have listed in your application, your curriculum vitae,
and personal statement. Be very familiar with your research,
extra curricular activities, your strengths and weaknesses.
A few weeks prior to the interviews, you may start preparing
for interviews in several ways. Practice for interviews by
making a list of potential interview questions and answering
them. Participate in any mock interview opportunities made

available by your school or elsewhere. You may just ask your
senior residents and attending physicians at your clerkship to
have mock interviews with you. Avoid any textbook, generic
and over-prepared answers as you may sound just like the
previous interviewees. Instead, you should be spontaneous
and give personalized and sincere answers, which has more
impact and lasting effect.
Learn well about the programs that you are being
interviewed before the interview day. Ideally, you have
done some research before even applying to each program,
so you already know if it is the right place for you. Most
programs provide extensive and informative overviews of
their residency program in their websites. Many of your
questions can be answered after reading all the information
provided in their orthopedic residency program website or
related links. A couple hours of online search can provide
you with much valuable information about the program, the
city and its neighborhoods, the region geography, economy,
culture, attractions, and the housing options. This will also
help reduce some anxiety during the interview as you will
not feel a complete stranger to the program. You will not find
out who will interview you until the day of your interview;
however, applicants can expect to be interviewed by either
the program director or the chairman and some of the
senior residents. Therefore, you can learn beforehand more
about these individuals or other attending physicians, their
specialty of interest, or their research backgrounds on the
program website. The last few nights before the interview are
an excellent time to look up this information so it will remain
fresh in your mind.
SOCIAL EVENTS
Most programs have a social event either the night before or
after the interview. Attendance at this event is optional, but
this is perhaps the best opportunity for applicants to learn
more about the program. Residents usually host these events,
so this is a wonderful opportunity for you to get to know them
and ask questions in a relaxed and informal setting. Therefore,
we highly recommend that applicants attend the social
events. However, if for any reason you are not able to attend
these events (because of interview scheduling conflicts, for
example) then you should not be overly concerned, as this will
not be held against you. Again, this is mainly an opportunity
for applicants to get to know the program better.
If you attend any of these events, do not consume
alcoholic beverages beyond moderation. You should plan on
leaving the event early enough so that you can get adequate
rest the night before your interview. Make sure your interview
attire is clean and ready the night before the interview.
THE INTERVIEW DAY

Do not be late. Make sure to give yourself enough time to get
ready in the morning and plan to arrive to your interview
place 15 minutes earlier than the time you are asked to arrive.
There is nothing worse than being late on your interview
day and arriving in the middle of the program director or
the chairman’s talk. By getting there early, you can meet
the other applicants and grab a bite, as most places provide
refreshments. Make sure to bring a snack with you in case it
was not provided or you did not find time to eat before the
interview. It is important to be awake and energetic at all times
during your interview; however, you should avoid consuming
too many caffeinated beverages unless this is a regular habit
for you.
Pay attention to instructions and interview day schedules,
and keep track of time. Having a notebook will allow you to
take notes if needed during the introductory presentations,
as a lot of information will be presented during that time.
Do not try to take notes during your actual interviews, but
instead pay attention to the questions as well as your answers.

Plan for and expect the interview to take place for half a day
if you need to arrange transportation or travel plans. Most
likely several people in multiple rooms throughout the day
will interview you. Sometimes interviews are right after each
other, but most times there are gaps between interviews. You
will also be given tour of the hospital(s) and facilities at some
point during your interview. You will generally be given the
opportunity to meet the residents again and ask any questions
that you might have. This is especially beneficial if you were
not able to attend the social event. Refer to the list of suggested
questions below that you may want to ask residents.
INTERVIEWS
You will be given interview schedules with the name of the
interviewers, times, and locations. As with any other social
meeting, the first impression plays an important role. As you
enter each room, smile, look the interviewers in the eyes, stay
calm, and shake hands firmly. Listen and respond thoughtfully
to interview questions. Speak clearly and answer questions
completely but concisely as time is limited and there might be
different interviewers in the room and each with questions of
their own. It is okay to be interactive and shift the direction of
the interview slightly with your own questions or comments.
This is especially beneficial when your interviewer is not
very talkative or prefers an open approach where you are
asked open-ended questions. An example of such questions
would be “tell me about yourself”. Do not be afraid to ask
the interviewer to repeat or further explain a question.
Be energetic and confident but also be modest. You do not
want to be seen as an arrogant person. Stay engaged and
attentive and maintain eye contact with the interviewers in
the room throughout the interview.
Expect questions about your application, personal
statements, academic, and life experiences. Many inter
viewers might be reading your application and personal
statements for the first time just a few minutes before you
enter the room. They may therefore ask you simple or general
questions, as they might not know anything about you and are
just interested in getting to know you.
Interviewers should not ask certain questions. Questions
about religious beliefs, marital status, sexual orientation,
and your ranking preferences are inappropriate. Although
you may encounter these questions, you are not obligated to
answer them and you may politely refuse to answer. Toward
the end of each interview, you will be given a chance to ask
any questions you may have.
STAYING IN TOUCH AFTER THE INTERVIEW

Students sometimes wonder if they need to send e-mails
or thank you cards to interviewers. Most programs rank
applicants immediately after the interview so your thank you
card may not be necessary. If you are particularly interested
in a program, it is okay to send the program director an e-mail
mentioning your interest without specifying details about
your rank list. This way you have not violated any rules and
will be in accordance with the National Resident Matching
Program (NRMP) policies.
The following is just a sample list of the questions that
you may be asked in your interviews. However, by no means
should applicants rely solely on this list as any questions
from your applications or outside of your applications can be
asked.
Questions that interviewers may ask you:
1. Tell me about yourself.
2. What made you decide to go into orthopedic surgery?
3. What made you interested in our program?
4. Tell me about your weaknesses.
5. Tell me about your research project.
6. What are your future academic goals?
7. What are your future life goals?
8. What do you do for fun?

9. Tell me about an interesting/challenging case.
10. You might be asked to interpret an X-ray or magnetic
resonance imaging (MRI) of an orthopedic-related case.
The following is a list of questions that you may be
interested in asking the program director or the chairman:
1. What are some aspects of the program that could be
stronger? What are the main strengths of the program?
2. Are there any anticipated changes in the staff or the
curriculum in the next few years?
3. How many applicants do you interview and how many
people do you rank?
4. How do you see the future of this program?
5. What qualities do you look for when interviewing
applicants?
6. Any other questions you may have for them.
Questions to ask from other attending physicians:
2. What research opportunities are available?
3. Do you feel the fourth- and fifth-year residents are
confident in handling common “bread and butter”
orthopedic cases on their own?
4. How do you see the future of this program?
Questions to ask from the residents:
2. Are you or most residents happy here? Are you happy
with your training or your life here?
3. How are the didactics and teachings?
4. How early into your training do you get to scrub as a first
assist?
5. Do residents get along with each other here?
6. How are the interactions and the relationships between
the residents and the attending physicians?
7. Do you feel you see and scrub into a broad range and
adequate number of cases to become confident by the
end of your residency training?
8. What are the housing options and the pricing in the area?
9. What do residents do in their spare time for fun?
10. What are the program alumni fellowship statistics in the
last few years?
11. What are the opportunities for research?
12. Are you expected to pay for parking, meals, or other
expenses?
13. If you had a choice, would you come back here for
residency?
14. What percentages of residents rotated or went into
medical school here?
Interestingly, most residents have biased toward their
own programs and may not reveal any negative aspects of their
program. However, by talking to as many residents, attending
physicians, and other applicants or medical students gain
more insight about each program.
summary
Here are our recommendations for interviews:
•• Do not panic if you did not receive any interview offers
well into November.
•• Check your e-mails frequently and reply to interview
offers quickly.
•• Arrange your interview travels early so that you can take
advantage of the cheaper flights. Sometimes you may
even be able to travel directly from one interview place to
another destination.
•• Start preparing for your interviews early, preferably weeks
before the interview season starts.
•• Learn about the institution and their orthopedic program
as much as possible before your interview.
•• Plan to arrive to your interview destination at least one

day prior to your interview to avoid possible delays or
flight cancellations due to weather conditions.
•• Plan to attend the social event of each interview.
•• Make sure that your interview attire is clean and ready the
night before the interview.
•• Make sure to have a snack or energy bar with you in case
refreshments are not provided.
•• Avoid too many caffeinated drinks.
•• Make sure to arrive early on your interview day. Give
yourself enough time in the morning to get ready for trans
portation, parking, and finding the interview location.
•• Stay professional, calm, happy, and energetic at all times.
•• Be respectful and nice to everyone, get to know the
residents and other applicants, and enjoy your time there.
•• As you enter each interview room, project your confidence
and professionalism by shaking hands firmly, maintaining
eye contact, having a smile, and addressing every one as
they were introduced to you.
•• Listen to questions carefully, and answer questions
thoroughly and thoughtfully but concisely.
•• Address and maintain eye contact with everyone in the
room throughout the interview.
•• Do not panic if you are asked questions that are out of the
ordinary or atypical.
•• Be honest, at all times.
•• At the end of your interview, again shake hands with
everyone and thank them for their time.
•• It is okay to send an e-mail to follow-up after the interview
and mention your interest. However, it is not necessary to
send thank you cards to all those who interviewed you.
7
Orthopedic Programs
and the Ranking
Process
Sean E Mazloom, Andrew Tsai
THE NRMP MATCH
Now that you have completed your interviews, it is time to

make a formal ranked order list, rank list for short, of the
programs using the National Residency Matching Program
(NRMP) system. The NRMP is a non-profit organization
created to provide a fair, simple, and valuable matching
system for both applicants and programs in the United
States. Applicants use the rank list to indicate their programs
of interest. Each residency program submits a similar list of
applicants he or she is willing to accept into the program in
order of preference. NRMP then uses these rank lists to match
applicants into the available residency positions of their
interest.
You have the option of ranking as many programs in
any particular order as you wish. You can also rank different
programs in different specialties if this is your intention.,
Practically, you should only rank programs that you were
interviewed for and in the order of your interest. In terms
of fees, NRMP charges $60 for the first 20 ranked programs
and $30 for each subsequent program ranked. Though most
applicants will chose to rank all programs at which he or she
was interviewed, you can rather be selective and do not need

to rank all of them.
The ranking process can be a challenging and daunting
task, and you might be tempted to make frequent changes
to your original list. However, we highly recommend that
you make your final rank list, at latest, a week before the
deadline date and certify it. Once you certified your rank list,
avoid making last-minute changes that can be the result of
panic and uncertainty and not necessarily logical and well
planned. You should also be familiar with the NRMP Match
Participation Agreement, as any breaches of this agreement,
including failure to provide complete, timely, and accurate
information during the interview and matching process,
discrepancies in graduation credentials, attempts to subvert
eligibility requirements or the matching process itself, and
failures to offer or accept an appointment may result in serious
consequences such as withdrawal of the application or the
program from the match. Other prohibited actions include
irregular behavior or activities that occur in connection with
registration, submission or modification of a rank order list,
and/or the participant’s commitment to honor the match
outcome. For more information on this please refer to the
“Policies” section on the NRMP: Residency Match Website.
FACTORS TO CONSIDER IN
RANKING THE PROGRAMS
Applicants and even some interviewers may not be familiar

with the ranking process and may find it complicated or
overwhelming. Here are some recommendations to make
this process easier and as effective as possible to achieve the
desired results:
•• In general, the more programs you rank, your chances of
matching will be higher. This is especially important when
applying to very competitive residency programs such as
Orthopedic Programs and the Ranking Process 73
orthopedics. Therefore, rank all the programs, where you
have interviewed and are interested unless you absolutely
have no interest in a particular program.
•• Rank programs based on your own interests and
preferences and not based on how you think programs
will rank you. Your overall chances of matching should not
change based on your preference list.
•• Determine and know your priorities and preferences
well, as it will make it easier to rank programs. Applicants
view, and therefore rank programs differently based on
the programs’ location, environment (urban, community,
or rural), reputa tions, lifestyle, culture, didactics and
teaching quality, academic level (academic versus comm
unity-based), and the residents’ characteristics. We cannot
make recommendations on which program best suits you,
as this is an individual preference. One program may be
an excellent choice for one applicant but not for another,
so it is primarily you, and possibly your partner, who have
to make this decision. As a good rule of thumb, you can
make your rank list based on where you will be happier
and see the potential of maximizing your education and
training.
•• If you are not a very strong candidate for orthopedic
surgery, you should have a back-up plan. We will cover this
in more detail later in this chapter but, briefly, if you do
not want to go unmatched, you should perhaps consider
applying for less competitive specialties, such as general
surgery, in addition to orthopedics.
•• Do not rank the programs that you have no interest in
matching. Once you are matched into a program, you
are obligated to adhere to the rules by accepting the offer
and completing the residency program. Please refer to the
NRMP Website and read the section on “The Integrity of
the NRMP Match” to learn about match violations. We
have also provided a list of examples of such violations by
either applicants or programs at the end of this chapter.
ACADEMIC VERSUS COMMUNITY

ORTHOPEDIC PROGRAMS
Residency programs can be classified into a spectrum from
very academic to nonacademic. No one can tell you with
certainty which program best fits you, and this is not our
intention here either. We will provide you with some facts
and general information about each type of program but,
ultimately, it is up to each individual applicant to make the
final decision.
In general, university-based orthopedic programs tend
to be more academic than the programs not associated
with a university setting. This is mainly because of the focus
of universities and hence the larger resources allocated to
research in such institutions. Some academic programs may
have an additional year designated for research, which further
emphasizes the dedication to research by these programs.
University-based academic programs attract larger research
funding (i.e. NIH funding), which enables them to build
the infrastructure and assemble the resources necessary for
conducting basic science and large-scale clinical research.
But why is research such an important component of
any field in medicine including orthopedics? Simply put, it
will be only through continuous investment and involvement
in bench and bed-side research that we can bring about the
largest impact in the future of orthopedics and assure the
highest quality of patient care. Furthermore, involvement in
research is of great importance when applying for fellowships
and jobs, especially if you are considering an academic career
in the future. In addition to becoming a surgeon during
residency, the process of learning to conduct research will
help strengthen your critical thinking skills.
The faculty in university-based hospital programs is
usually composed of several full-time attending physicians in
addition to the part-time and volunteer physicians dedicated
to training residents. Many of these orthopedic surgeons are
experts and leaders in their subspecialty and usually have years
of experience in training residents. Most academic programs
cover a wide spectrum of subspecialties in orthopedic surgery
by having the resources and the faculties in each of those
areas. This breadth and depth of coverage allows residents
to see and manage a wide variety of patient cases including
the complicated, uncommon, and even rare cases that do not
usually present to smaller, community hospitals.
Residents at academic programs mainly work in the
teaching hospitals and facilities (including the VA system),
but usually rotate at private or outpatient facilities as well.
This provides a unique opportunity for residents to work
in different settings and treat diverse patient populations.
Additionally, if associated with a university or medical school,
residents may have the opportunity to teach medical students.
Having a fellowship program is another unique aspect of
many academic programs. Having fellows around can affect
your training in different ways, depending on the institution.
Programs can offer fellowship programs in one or more
subspecialties. Depending on the size of the program and
patient volume, one or several fellowship positions in each
subspecialty may be offered. Programs also vary in terms of
the scope of the fellows’ responsibilities and the coverage of
daily cases. In general, fellows are more inclined to take on
the more complicated and advanced cases, but unless you’re
a senior resident, you probably will not participate in those
complex cases anyway. Fellows can provide residents with
excellent teaching opportunities, as most enjoy teaching
residents and are willing to take the time to do so. As recent
graduates, they can better relate to residents, understand
their needs, and provide them with valuable teaching and
advice. On the other hand, having fellows at low-volume
programs can hinder valuable time in the OR for residents.
In such places, residents may not get quality time in the OR
until their third year of residency! Therefore, be aware of such

variances in programs. The best way to understand the role of
fellows at a particular program is to ask the residents and the
faculty during interview day.
Community-based programs are generally smaller, take
fewer residents, and more commonly cover only one hospital.
However, similar to academic programs, opportunities for
private setting OR and clinics are usually available. Also
similar to academic programs, these programs vary in
terms of volume, didactics, and training they provide for
residents. Most community programs provide more one-
on-one interaction, and “first assist” opportunities with
attending physicians, and may allow earlier OR experiences
than many academic programs. On the other hand, the
opportunity to see a wide a spectrum of disorders especially
rare cases and procedures may be limited. Additionally, most
community programs are limited in terms of infrastructure
and resources available for research. Therefore, if you are
research-minded or considering a career in academia, your
access to research opportunities at a community program
may be limited compared to academic programs. In some
settings, either academic or community-based programs,
the senior to junior residents supervision and teaching may
replace the attending role. However, the caveat is that it takes
supervision and guidance from experienced teachers and
surgeons for residents to learn how to and, more importantly,
when to operate. Although there are many well-rounded and
comprehensive community-based programs, some may not
cover all areas and subspecialties of orthopedic surgery. This
is not to say that all academic programs are well rounded
and cover all the subspecialties, but if you are particularly
interested in an orthopedic subspecialty, then make sure that
the program of your choice covers that area well so you will
have adequate exposure. Finally, as many community-based
programs are located in rural areas or smaller cities, make
sure that you would enjoy that living environment.
In conclusion, academic and community-based ortho
pedic programs vary with respect to the number of residents,
hospital settings, teaching styles, patient diversity and volume,
intensity of training, quality operative experiences, and the
living environment. All orthopedic programs (academic or
community-based) must follow certain guidelines in their
teaching curriculum and OR times. Subsequently, most ortho
pedic surgeons who have completed their residency program
in the United States are adequately trained in managing
the basic and the “bread-and-butter” orthopedic cases.
Regardless, orthopedic surgery is an extremely competitive
field, and gaining acceptance into any program is a great
achievement. Ultimately, it is the individual’s effort and hard
work rather than the type of the program, which enables a
resident to succeed in becoming an outstanding orthopedic
surgeon.
MATCH RESULTS INFORMATION
The NRMP releases match results in a five-day period during

Match Week. At 12:00 noon Eastern Time on Monday March
17, 2014 applicants will be only informed of whether they
successfully matched or not. Also on this day locations of
all unfilled positions are released to applicants eligible for
the Supplemental Offer and Acceptance Program (SOAP).
On Match Day, March 21, 2014 you will find out which
program you have been matched to.
On the Monday of Match Week, you will receive one of the
following messages via e-mail:
Congratulations, you have matched!
This message will be displayed for any applicant who is “fully”
matched. You will also receive this message if you applied to
other categorical programs, to both preliminary and advanced
programs, or if you only applied to preliminary programs and
have matched.
Congratulations, you have matched to an advanced position

but not a first-year position!
You will not receive this if you only applied to orthopedics.
If you applied to other programs besides orthopedic surgery
with advanced and preliminary positions (diagnostic radio
logy for example) and you only matched into the advanced
program but not the preliminary position, may receive this
message.
Congratulations, you have matched to a one-year position!
Again, this means that you did not match into either an
orthopedic surgery position or any other advanced positions
you applied for. However, you are matched into a preliminary
position.
We are sorry; you did not match to any position
This message will be displayed for any applicant who did
not match to a program listed on either the primary or
supplemental rank order list.
You are NOT matched because you did not submit a certified
rank order list
This message will be displayed for any applicant who
registered to participate in the Match but did not certify a rank
order list prior to the rank order list certification deadline.
You are NOT matched because you are withdrawn
This message will be displayed for any applicant who
registered to participate in the Match but was withdrawn
either by the medical school or by the NRMP.
Please refer to Chapter 8 in this book “What if You Do Not
Match” to learn more about your options if you did not match
into any program.
2014 Main Match Schedule

September 15, 2013 Registration opens at 12:00 noon eastern time
for applicants, institutional officials, program
directors, and medical school officials
October 1, 2013 MSPEs are released to ACGME accredited and
American Osteopathic Association (AOA)-
accredited programs.
November 30, 2013 Applicant early registration deadline
Note: Applicants may register for $60 until
11:59 pm eastern time. Applicants who regi
ster after November 30 must pay an addi
tional $50 late registration fee ($110 total fee)
until February 26, 2014, when registration
closes.
January 15, 2014 Rank order list entry begins
Applicants and programs may start entering
their rank order lists at 12:00 noon eastern
time.
January 31, 2014 Quota change deadline
Programs must submit final information on
quotas and withdrawals by 11:59 pm eastern
time.
February 26, 2014 Deadline for registration and ROL
certification
Rank order list certification deadline
Applicants and programs must certify their
rank order lists before 9:00 pm eastern
time. Staff will be available to answer your
questions during the final deadline hours.
Certified applicant and program rank order
lists and any other information pertinent to
the Match must be entered in the R3 System
by this date and time.
Withdraw deadline
Independent applicants who have accepted
a position through another national matc
hing plan or by agreement outside the Matc
hing Program must withdraw before 9:00 pm
eastern time.
March 17, 2014 ● Applicant matched and unmatched infor

mation posted to the Website at 12:00
noon eastern time.
● Filled and unfilled results for individual
programs posted to the Website at 12:00
noon eastern time.
● Locations of all unfilled positions are rele
ased at 12:00 noon eastern time only to
participants eligible for the Supplemental
Offer and Acceptance Program (SOAP).
March 18, 2014 ● Programs with unfilled positions may start
entering their Supplemental Offer and
Acceptance Program (SOAP) preference
lists at 11:30 am eastern time.
March 19, 2014 ● Programs with unfilled positions must
finalize their first-round Supplemental
Offer and Acceptance Program (SOAP)
preference lists by 11:30 am eastern time.
March 20, 2014 ● Supplemental Offer and Acceptance
Program (SOAP) offer rounds begin at
12:00 noon eastern time.
March 21, 2014 ● Match Day! Match results for applicants
are posted to Website at 1:00 pm eastern
time.
● Supplemental Offer and Acceptance
Program (SOAP) concludes at 5:00 pm
eastern time.
March 22, 2014 ● Hospitals begin sending letters of appoint
ment to matched applicants after this
date.
EXAMPLES OF VIOLATIONS
Agreements Made by Match
Participants Before the Match
•• A program accepts and signs an agreement with a senior
student in a US allopathic medical school before Match
Day.
•• An applicant requests a contract before the announce
ment of Match results.
•• An applicant commits to a concurrent year training
position outside the NRMP Match and does not withdraw
from the NRMP Match. (This includes an applicant who
matches to a concurrent year PGY-1 position in another
match that precedes the NRMP Match).
•• A program director “guarantees” an applicant that he or
she will rank the applicant within the program’s quota, but
only if the applicant will rank the program first on his or
her rank order list.
•• An applicant “guarantees” a program director that he or
she will rank the program first on their rank order list, but
only if the program director will rank the applicant within
the program’s quota.
Violations During Match Week

•• An unmatched applicant contacts a program in the Match
to seek a position before noon eastern time on Tuesday of
Match Week.
•• A program director, anticipating that the program will not
fill all of its positions, contacts a student affairs dean on
Monday of Match Week to find out which students did not
match.
•• A student affairs dean consults with faculty and other
colleagues about possible openings before the beginning
of the “scramble period”.
•• A student affairs dean consults with students about their
match status prior to the release of applicants’ match
results on Monday of Match Week.
Not Honoring Results of Match

•• An applicant decides not to honor the commitment to
his or her matched VDD program and does not seek a
waiver I.
•• A matched applicant accepts a position in another

program.
•• An institution adds new appointment requirements that
were not communicated to applicants prior to the rank
order list deadline.
•• A program director interviews an applicant who matched
to a concurrent year position in another program and who
has not obtained a waiver by the NRMP.
•• A program director approaches an applicant who is
matched elsewhere to explore the possibility of having the
matched applicant switch programs.
•• A program decides not to honor its commitment to a
matched applicant who satisfies all the appointment
requirements.
•• A program involved in a waiver investigation fills the
position prior to NRMP approval of the waiver request.
•• A program seeks a waiver from a commitment to a
matched applicant in order to offer the position to another
applicant.
•• A program offers a position to an applicant whose waiver
request was denied, and training commences during the
applicant’s one-year prohibition from accepting a position
in any NRMP match-participating program.
8
What If You
Do Not Match?
Sean E Mazloom
Each year over 17,000 US allopathic medical school seniors

and nearly 17,000 graduates of osteopathic and foreign
medical schools compete for approximately 26,392 first-
year residency positions in America! In 2013, 163 orthopedic
programs offered 693 residency positions and 1,038 applicants
applied for these positions during that year. There was only
one unfilled program, with an overall 99.9% of positions being
filled! Of those 693 offered positions, 636 slots were filled
with US seniors, 34 with US graduates, 15 with international
medical graduates (IMGs), and 6 with osteopathic applicants.
Of importance, nearly 25% of US seniors, and more than 87%
of independent applicants who applied to orthopedic surgery
in 2013 did not match to a program in this field!1 Though not
meant to be discouraging, these facts clearly indicate the
competitive nature of this field.
As heartbreaking as it sounds, this difficult situation will
be an unfortunate reality some applicants have to face when
applying to any competitive residency like orthopedics. More
importantly, this possibility exists for almost every applicant
and should not be taken lightly. Therefore, it is wise to expect
the unexpected, to be familiar with all your options, and to
plan ahead prior to receiving the match results. Here are two
questions you should ask yourself, early on, when considering

any competitive specialty like orthopedics: are you willing to
wait another year, or more, and reapply to orthopedics? And,
do you have any “backup” plans such as applying for a less
competitive filed of interest in medicine? Having clear backup
plans in advance will make it easier to face the potential
unwanted match result and to move forward expediently.
This chapter focuses on these important issues and discusses
various options that candidates may consider.
“Why Didn’t I Match?”

The very first question you need to ask yourself is “Why didn’t
I match?” By identifying your weaknesses and the reasons you
did not match, you can address them properly and find the
next best solution and course of action. If you cannot find a
reason, contact your academic advisor or another supportive
member of your medical school to help you review your
application and figure out the ways you can improve your
application. Re-applying the following year with an identical
application is unlikely to yield any better result.
Two major routes that unmatched applicants take are
applying to another field of medicine (i.e., general surgery)
or taking a year (or more) off for research. However, be aware
that if the reason for not matching into orthopedics was poor
academic and clinical performances (i.e., board scores, and
clinical rotation scores), then you may still not be able to
improve your chances sufficiently even after a year of research
or other extracurricular activities. Hence, identifying your
application weaknesses prior to taking any further actions
allows you to make more logistic decisions.
SOAP
Beginning at noon Eastern Time (ET) on Monday of Match
week, applicants who were not matched are given a brief
What If You Do Not Match? 85
opportunity to contact residency programs only through
ERAS for unfilled residency positions. This process called “the
scramble” in the past has been modified and is now officially
named the Supplemental Offer and Acceptance Program
(SOAP) by the NRMP. Details on the newly introduced
SOAP can be found on the NRMP website, which explains
the process in detail. SOAP allows initial contacts between
applicants and programs only through ERAS, although phone
interviews are common practice during SOAP. Only qualified
applicants and registered users of NRMP’s R3 system are
entitled to have access to this information. The SOAP process
discussed here is mainly towards applicants with plans to
match into alternative and less competitive specialties, as
there are very infrequently any open spots in orthopedics
after the first round of match.
The SOAP process for unfilled residency positions will
take place in a five-day process right after the initial match
results are sent out. All applicants are encouraged to refer to
SOAP instructions prior to match week in the unfortunate
event it becomes necessary to undergo but here we provide a
brief summary of how it works. We will further discuss various
options and recommendations for the unmatched applicants.
SOAP Details
•• On Monday of Match week, applicants are notified
through NRMP if matched or not at 12 pm ET. The NRMP
list of unfilled positions is also released at the same time.
Applicants may begin ERAS application on the same
day and have 3 days (until Wednesday at 11:50 am ET)
during the first round to send their applications to up to
30 programs. Programs can start telephone interviews on
Monday but positions cannot be offered until Wednesday.
•• Starting at 12 pm ET on Wednesday, programs may begin
offering positions to applicants, whom can either accept
or reject the offers.
•• Applicants who still have no positions after the first round,

may participate in the second round of the SOAP, which
begins on Wednesday at 12 pm ET and ends on Thursday
at 11:59 am ET. Applicants can send up to 10 applications
to programs in this round. Programs may start offering
positions at 9 am ET on Thursday.
•• The last round of SOAP takes place from Thursday 12 pm
ET until the conclusion of SOAP on Friday at 5 pm ET and
up to 5 applications can be sent in this round. The final
round positions will be offered on Friday.
•• Applicants can accept or reject extended offers from
programs after each round in the R3 system.
•• Fortunately, you may apply to different specialties than
the initial specialty(s) that you applied for in the main
match. For example, if you only applied to orthopedics
initially, now during SOAP you can apply to any other
specialty that interests you! Applicants can further
submit a new personal statement and even new letters of
recommendation.
SOAP Options
1. Apply to any unfilled orthopedic surgery positions. As
we have mentioned earlier, there are usually very few
unfilled orthopedic positions available after the match.
For example, there was only one position available after
the 2013 match. Therefore, do not count on this!
2. Apply to unfilled preliminary general surgery positions.
Completing a preliminary year in general surgery
allows you to gain invaluable clinical experiences,
have a source of income, and still be able to reapply to
orthopedics the following year. Meanwhile you can get
involved in orthopedic research on your spare time. As
orthopedic surgery and general surgery departments
work closely with each other in many institutions, this
could be a chance for you to get to know the orthopedic
residents and attending physicians who may consider
your application the following year. In rare cases,
PGY2 orthopedic positions may become available and
those applicants who have completed a preliminary
year of general surgery may apply for those positions.
The caveat is that as orthopedic programs are changing
the structure of their intern year curriculum, the newly
introduced “orthopedic-focused” intern year will perhaps
become mandated for most programs prior to starting
the PGY2 year.
3. Apply to categorical general surgery. Applicants who are
primarily interested in completing a five-year general
surgery program should choose this path. If you are
still interested in pursuing orthopedic surgery after
completion of the general surgery residency program,
you can apply to and complete the orthopedics training
in another three years. You should not plan on choosing
this path if your intention is to reapply and switch to
orthopedic surgery after completion of your intern year.
This may place the general surgery program in a difficult
position as they will lose a resident, and it may have
negative consequences for you. As mentioned earlier, the
newly introduced “orthopedic-focused” intern year may
eliminate the option of applying to orthopedics PGY2
positions after one year of general surgery internship
altogether.
4. Apply to a preliminary internal medicine position.
Similar to the preliminary general surgery option, this
will give you the opportunity to start working as a resident
and avoid an interruption in your clinical training, while
you can still apply the following year for an orthopedic
or another advanced residency program position. Again,
applicants should focus on strengthening their appli
cation for orthopedic surgery through research involve
ment and taking orthopedic electives if possible.
5. Apply to any other categorical residency position. If you

are interested in any other field of medicine besides
orthopedic surgery and you do not want to wait another
year to reapply to orthopedics, this option suits you. There
are many interesting and fascinating fields in medicine
and you should investigate and explore all your options.
6. Take an year off. If you are planning to take an year off,
then do not participate in the SOAP process. This option
can provide great benefits; however, it should be carefully
chosen for several reasons. An year off clearly allows
you to dedicate an entire year to strengthening your
application in many different ways. Importantly, you can
spend a great deal of time examining whether you truly
wish to pursue orthopedics, and whether you are willing
to do what is necessary to bolster your application and
improve your chances. Involvement in orthopedic clinical
and basic science research, in addition to orthopedic
rotations may tremendously improve your chances if your
application “was good on paper” but lacked adequate
research or other orthopedic-related work. As mentioned
previously, research and extracurricular activities cannot
compensate for poor academic results and board scores.
Additionally, you should consider and plan your finances
carefully when taking an year off, as limited or no source
of income including grants or financial aid may be
available to you. A handful of institutions may provide
financial aid options if you make an year or two-year
research commitments and it may well be worth looking
into those options beforehand. As a side note, if you
decide to take an year off during medical school, most
schools allow you to delay graduation, further enabling
you to continue utilizing your medical school’s resources
during the following year’s application cycle. However,
as mentioned earlier, none of the above will guarantee
candidates a residency position in orthopedics in the
following year(s). In 2013, only 34 US graduates (not
medical school seniors) in total were offered a PGY1
orthopedic residency position. Regardless, experiences
and achievements one gains through any of the aforem
entioned routes can be tremendously invaluable and
may even be applied toward any residency application or
future career goals.
In summary, applicants can better overcome the challe
nges and make appropriate decisions if they prepare and
plan for the unexpected results in advance. Identifying
one’s application weaknesses, in addition to fully exploring
other potential interests and passions in medicine will allow
candidates to successfully redirect their focus in order to
achieve the best possible outcomes. Applicants should know
that many alternative options exist if not matched in the first
place. After all, there are many fascinating fields in medicine,
where one can make a difference and have an exciting and
rewarding career.
Reference
1. National Resident Matching Program, Results and Data:
2013 Main Residency Match®. National Resident Matching
Program, Washington, DC. 2013.
9
Research: Before and
During Residency
Sean E Mazloom, Jonathan Streit
Extensive basic science and clinical research attention and

resources made available to orthopedics in the last few
decades, has made it one of the most robust and advanced
fields in medicine. New instruments and prosthesis designs,
new approaches, and discoveries are introduced to ortho
pedics on a daily basis, thanks to the dedicated work of many
clinician scientists and researchers. On the other hand,
sub-specialization of orthopedics has enabled research in
many new areas of interest for clinicians and researchers.
Consequently, research has become an integral and vital
aspect of orthopedics. Not surprisingly, most, if not all, of
the top orthopedic programs in the nation have focused and
invested heavily in orthopedic research and are tremendously
interested in applicants with strong research backgrounds.
After all, it is only through full investment and involvement
in quality basic science and clinical research that we can keep
the promise of providing better care for our patients in the
future.
In the latest NRMP orthopedic surgery program directors
survey released in 2012, 71% of the programs listed research
involvement as a factor in selecting applicants to interview.1
However, research involvement on its own is not a decisive
factor in ranking applicants. For instance, those US graduates

who applied but did not match into an orthopedics program
in 2011 on average had an average of 2.8 research experiences,
and a mean of 3 for abstracts, presentations, and publications.2
Simply put, research cannot replace or compensate for poor
performance in the USMLE Step 1 examination or clinical
clerkships grades. Regardless, research involvement can
benefit applicants in a variety of ways and make their appli
cations more attractive.
The undergraduate years are an excellent time to get
involved in research projects and learn the fundamentals of
conducting scientific research. Many orthopedic scientists are
greatly interested and benefit from the work of undergraduate
students and have available projects for students. However,
most pre-medical undergraduate students have not devel
oped preferences in a particular field of medicine and may
not specifically think about doing research in orthopedics.
Regardless, taking an year or more off to do research after
completing an undergraduate degree has become increasingly
popular among pre-medical applicants.
The first year of medical school is another great time to
get involved in orthopedic-related research. You will have
more free time during the first year, and this will also allow
you to continue working on your project throughout medical
school. Some schools may provide an allocated research time
during the third or fourth year, while other schools may allow
you to take a third-year rotation off for research. Numerous
opportunities for research, presentations, and publications
exist at most academic centers as long as you are interested
and take the initiative in getting involved.
TAKING An YEAR OFF DURING OR AFTER

MEDICAL SCHOOL FOR RESEARCH
Taking an year off is yet another pathway for applicants

who are interested in research to get intimately involved
Research: Before and During Residency 93
in orthopedic-related projects, learn more about the field,
and explore their own interests. Depending on student’s
motivation and background, tremendous amount of academic
work, and publications can be accomplished during a year.
Doing research in any orthopedic department also provides
an opportunity for applicants to get to know the faculty and
participate in clinics and surgical cases.
An year off for research can be requested after the second
or third years of medical school, or even after graduation. The
timing may be based on each person’s individual preferences
and overall situation. In general, between the third and fourth
year seems to be a great time for research as the combinations
of both basic science and clinical rotations can prove
invaluable for involvement in orthopedic-related research
along with related clinical activities and projects.
Types of Research
Basic Science Research
Basic science or “bench” research is designed to bring about
understanding of the fundamental principles of a particular
scientific field. It further generates questions, ideas, theories,
and advances the level of understanding. Orthopedic basic
science research lies at the interface of multiple disciplines
including biomechanics, biochemistry, immunology, patho-
logy at the cellular and molecular levels, physiology,
and anatomy. Because of the complexity of orthopedic
laboratories, students are valuable participants in these
projects, which often require months or even years of data
collection and time spent in the lab. These projects usually
mandate involvement on a long-term basis. Although the
time investment is great, the rewards are even greater, since
students who put time and effort into these studies are few and
far between. Medical schools and residency programs place a
premium on students who have basic science knowledge and
have demonstrated the initiative and capacity to work on a

project through its completion.
Clinical Studies
Planning, carrying out, and publishing the results of a good
clinical study takes a lot of effort. Many orthopedic surgeons
are involved in a number of clinical studies at any given time
and can always benefit from extra help with such projects.
Given that little clinical experience is necessary for the
seemingly mundane tasks of data gathering and analysis,
students in particular can greatly help with such projects.
Don’t be surprised or offended to be relegated to a lower
level of authorship in these studies, as clinical experience
gives the principal investigator–the attending physician—or
perhaps even the residents the legitimate right to receive a
higher level of authorship. A curriculum vitae (CV) detailing
involvement in multiple studies with consistently high levels
of participation will impress selection committees for medical
school and residency.
Case Report Studies

Case reports are a type of anecdotal evidence that elaborate
on a patient who presented with a unique or rare symptom,
disease, course of disease, or treatment. Involvement in
these types of publications usually requires being in the right
place at the right time, and therefore your ability to become
involved is directly related to the amount of time spent in the
operating room or in the clinic with faculty. To get involved in
one of these publications, which are usually short and require
minimal investment in the actual reporting and publishing,
plan to spend as much time in the department as possible.
Asking an attending or resident, “Would this make a good case
report for a journal?” is a great way to show your interest and
understanding, and you may be rewarded with a relatively
easily-won publication for your troubles.
Book Chapters
Contributing to book chapters is another great way to get
involved in an orthopedic project. These require countless
hours of study, and the residents and attending physicians
who write them will spend a great deal of time sifting through
journal articles and previously written book chapters for
the information needed to write the chapters. Volunteering
to help out with these projects may earn you mention in a
“special thanks” portion of the chapter, but you are unlikely
to earn top billing simply because, like with clinical studies, a
good deal of knowledge and synthesis of ideas is required for
the ultimate authorship of the chapter, and this can only be
gained by experience. Still, those around you will notice your
efforts, and you can expect your rewards to come in the form
of strong, personalized letters of recommendation from the
faculty you assisted.
Presentations and Posters

Attending a national meeting and presenting research on the
podium or in the form of a poster is a great way to show your
dedication and to meet others in your chosen field. Many
meetings limit the number of projects that may be presented
by a given author, and so working with a particularly ambitious
attending physician may net you the opportunity to present
his or her research. This can be a great opportunity to show off
your professionalism and composure under pressure. It is also
something that will be reflected on your CV, and gives you a
point of interest that can be talked about during an interview.
Meeting the challenge of public speaking demonstrates true
dedication to your project and gives the selection committee
the impression that you are interested in academic and
leadership roles.
Factors to Consider when Taking an Year Off

Several important factors should be taken into consideration
before taking an year off. First, discuss this with school
advisors and perhaps those students who have done this in
the past to get a better understanding of might be ahead and if
this is the right choice for you.
Be familiar with school policies regarding taking an
year off and discuss this with a school advisor. Plan early and
search all the available options for research, preferably at
home institutions first and then elsewhere. Plan your finances
wisely, as this may become a decisive factor for some. Most
institutions will compensate the candidates who dedicate
an entire year for research; however, many places may offer
partial or no financing at all.
Have a clear understanding of your project, your role
and responsibilities, and timelines for specific projects. Plan
to have something to show for your time when your project
is finished. Becoming involved in a very large multicenter
project that has just started may not be wise if you are applying
for residency programs in the next few months. Taking an year
off to dedicate yourself to research will only be of benefit if
you can show that the time was spent to its fullest and was
not just a year of vacation. Program directors are well aware
of how much can be accomplished in an year, and they will
look for it to be reflected in your publications and letters of
recommendation from your research advisors.
Research During Residency

As stated earlier, the continued emphasis on high-level
orthopedic research has driven the field to where it stands
today. Research during residency offers the opportunity to
become involved in depth with these projects, with greater
rewards in terms of authorship and opportunities to present
the research at national meetings. Almost all programs
encourage residents to become involved in research, and the
level of opportunity and expectations for involvement are
things to consider when choosing a program.
Research as an orthopedic resident serves multiple
purposes. For those who are unsure of which subspecialty,
if any, they would like to pursue, involvement in projects
within multiple areas of orthopedics can offer a closer look at
each subspecialty. Involvement in research may be the best
way to decide early whether or not this is the field for you,
especially if your program offers rotations within a particular
subspecialty relatively late in the training experience, or
if your program simply does not offer much training in a
desired subspecialty. Second, just as with applications to
medical school and to residency, applications to fellowship
training programs and competition for desirable jobs
will inevitably lead to a review of your CV. Involvement
in research shows dedication and a desire to better the
field, and high-level involvement in as many projects as
you can handle will serve you well in this regard. Finally,
involvement in research is a great way to get to know your
attending physicians, and to form relationships with them
that involve more than simply taking care of their patients.
These are the people who can further your career, and doing
research with them is something that can become mutually
beneficial.
When considering a training program with research
in mind, determine whether a dedicated research year is
possible, or even mandatory, before you apply. If you are
looking for a lower level of involvement, those programs
that require residents to take time away from clinical duties
to do research may not be the ones for you. However, if you
want to set yourself up for a career in academia, these
programs may be a perfect fit. Some programs allow residents
to specify whether or not they would like to take an year off
for research and offer different application paths to their
program, offering perhaps a few “research track” residency

positions each year, and several more “non-research track”
positions within the same program. Usually the programs that
offer dedicated research time are those with higher levels of
NIH funding, and therefore their national rankings are often
at the higher end.
A dedicated year of research during residency carries
with it several advantages as well as a few disadvantages.
The advantages are mentioned well above: You will graduate
from the program with a CV that is strong and perhaps more
extensive than those of your attending physicians. You will
take on a special place within the department as a hard-
working resident—one who has earned a special place in the
hearts of those attending physicians with whom you have
worked, since you will have advanced their careers along
with your own. However, the time away from the hospital
will carry with it a temporary lag in your clinical knowledge
and abilities. This is usually anticipated by the department,
and is easily overlooked as long as you quickly get up-to-
speed in your clinical work after the research year is over.
And, of course, a research year means one more year added
to residency, which is not much when considered a part of
the long road to becoming an autonomous physician. But it
still can be disheartening as you see those in your incoming
class graduating from the program ahead of you. Additionally,
just as taking a year to do a fellowship sets you back a year’s
worth of pay, so does a research year. If you desire a career in
academics, a research year can be a great way to jump-start
your career and earn you a place in a high-powered fellowship
or academic department when the time comes. If you want
to practice as a community surgeon, however, a dedicated
research year may do little to advance your career. The choice
is a personal one that must be considered carefully.
Even if a dedicated year of research is not for you, almost
all orthopedic training programs now require their residents
to publish at least one paper by the time of graduation. Starting
the search early for a suitable project is to your advantage, as
even the simplest of research projects take years to complete
and to publish the results. It is not uncommon for a paper
to be submitted to several journals before acceptance and
ultimate publication. This can be frustrating, especially if you
have waited until more than halfway through your training
time to become involved in research. It doesn’t matter much
what you decide to pursue, since the experience of gathering
data, writing it up, and publishing it is virtually the same in all
orthopedic subspecialties. If you can determine your ultimate
path early, however, you can gain extra experience and
knowledge in your chosen field while endearing yourself to
those people who will be important in writing you letters and
making phone calls to make your fellowship and employment
dreams a reality.
Involvement in research as a resident can offer great
opportunities for recognition, which will really “get your
name out there” in the field. Doing a major share of the
research work and writing up the research should earn you
first authorship on these projects. The first author listed on
a publication is typically the one who wrote the manuscript.
The first author usually has the greatest understanding of the
research itself and its overall place within the body of work
in the field. Taking the time to read the background literature
is the only way to make this possible. All of these equate to
spending a great deal of time and focus on your project but
you can expect tremendous gain as a result.
For residents considering involvement with a project,
authorship expectations should be understood: The person
who writes the manuscript and puts in the most time
completing the project’s legwork and background research
should be the first author. The person who came up with the
idea for the project, whose clinical reasoning and knowledge
form the basis for the project itself, and whose experience
allows him or her to shape and guide the overall message

of the work through editing will be listed as the last author.
These are the two most powerful positions in the authorship
listing, and they are often considered to carry the greatest
weight when deciding on promotion within an academic
department. You may have come to realize that a number of
historically important publications bear the name of relatively
unknown surgeons. This is because the person who wrote the
paper ultimately did not develop a career that allowed them to
become a “big name” in the field, despite putting a great deal
of work into that one project. Closer examination of the article
would likely reveal that the last author is someone of note
within the field, and you may find that attending physicians
who understand this refer to papers by their last author’s
name, rather than the first. For instance, they may refer to
“Mike Smith’s article on femoral shaft fractures” when, in fact,
Mike Smith is not the first author, but the last. Second, third,
or lower levels of authorship go to those who put significant
work into the project but neither wrote the paper nor oversaw
the project. This level of authorship is still important, however,
as it allows the author to get credit for their work and increase
their overall number of publications.
In addition to clinical and basic science research pro
jects, residency training can be a great time to work closely
with an attending surgeon on a book chapter. Unlike the
low-level involvement that is expected of a student, the
expectations for residents are much higher in this area.
Working under the supervision of your attending physician,
you will likely author an entire chapter yourself, sending it off
to the attending physician for approval and edits when you
are finished. This works in much the same way as for writing
up research projects. Your dedication and involvement
should be recognized with primary authorship of the chapter,
with your supervisor listed second, or last, as the case may
be with chapters written by more than two people. Because
the number of books published is much smaller than the
number of research papers added to the ever-growing body
of literature, involvement as an author on a book chapter is
prestigious. These do take a great amount of time, however,
since book chapters may be up to 50 pages in length,
incorporating hundreds of papers and book chapters in the
overall synthesis of ideas. As with anything else, the level of
reward is commensurate with the level of work required.
SUMMARY
•• Understand the importance of research.

•• Familiarize yourself and get involved early on during
undergraduate and medical school years with multiple
research projects.
•• Know your options when considering taking an year off
for research.
•• Understand various types of research and basics of
conducting research and data analysis.
•• Have a clear understanding of the project.
•• Have a clear understanding of your roles and expectations.
•• Read as many articles and research papers as possible on
your topic of interest.
•• Seek financial support during research year if necessary.
•• Try to present your work at various seminars and
conferences.
•• If possible, get involved in various projects in different
fields of orthopedics to better learn about your interests.
•• Consider the expectations of residency programs with
dedicated research years and decided whether or not this
fits your overall goals.
•• Highly consider research if you are thinking about a career
in academia.
REFERENCES
Director Survey. National Resident Matching Program,
Washington, DC. 2012.
2. National Resident Matching Program, Charting Outcomes
in the Match, 2011. National Resident Matching Program,
Washington, DC 2011.
10
Women and Minority
Students Interested in
Orthopedic Surgery
Christina J Gutowski
INTRODUCTION
As the nation’s population continues to grow more diverse,
promoting gender and racial/ethnic diversity within the
medical profession has become an important issue in the
health care arena.1 Students who train in medical schools
with more diverse student bodies are more confident mana
ging patients from different cultures,2 and patients who
are managed by a physician from the same culture are
more likely to be satisfied with their treatment and with
their communication with the provider.3 While the field
has moved substantially toward achieving gender parity in
health care over the past decades, women and minorities
are still not represented equally in academic medicine—
this disparity is especially striking in orthopedic surgery.4
This field has experienced a stagnant rate of improvement
in diversity. The annual recruitment rate of female medical
school graduates into orthopedic surgery residencies did
not change substantially from 1970 to 2005 5 and, despite
a 38% rise in the number of women completing medical
school during that time, the proportion of women in
orthopedic surgery residency only increased by 10.3%.6
A recent study of ethnic diversity within the various medical

and surgical specialties found racial minorities to constitute
31.7% of orthopedic surgery residents, a number lower than
in any other specialty.1
The reasons behind the lack of diversity in orthopedic
surgery residency remain largely unclear. Proposed expla
nations include a lack of interest from minority and female
medical students, poor exposure to the field in medical school,
a lack of active mentorship and support by orthopedic faculty,
the gender/ethnicity of orthopedic department chairpeople
or residency directors, or differences in the qualifications of
white male applicants and minority applicants as measured
by standardized test scores, evaluations of externship
performance, etc.1,7
Despite the stark disproportion that exists, both faculty
and applicants rank gender and race as the two least
important attributes (out of 10 possibilities) possessed by a
medical student throughout the resident selection process.8
However, the groups’ perceptions differed slightly regarding
the statements, “gender does not play a role in the selection
process in orthopedics” and “race does not play a role in
the selection process in orthopedics”. In both cases, faculty
members agreed more strongly with these statements, while
applicants expressed more neutral feelings, measured on a
spectrum of agreement or disagreement. Therefore, while
most faculty members believe that gender and race do not
play considerable roles in the ranking process of applicants,
the applicants—especially women and racial minorities—
felt otherwise.8 Racial minorities comprise only 28.5% of the
pool of applicants to orthopedic programs.1 This imbalance
suggests that the problem is rooted in a cause occurring early
in the process, even before a residency program conducts
applicant ranking. The barrier appears to be in recruitment of
females and minorities to the applicant pool, as opposed to a
bias toward selecting white male applicants out of that pool.
Women and Minority Students Interested in Orthopedic Surgery 105
A study investigating the possibility of bias against female
applicants in the initial chart-review phase of the resident
selection process failed to show evidence suggestive of gender
influencing the evaluation of applicants.9 Furthermore, no
differences were found between male and female resident
performance on faculty evaluations or standardized test
scores, which would suggest there is no academic reason
for ranking committees to prefer male residents to females.10
These data support the notion that the gender and racial
disparities that exist are not rooted in barriers to entry created
by resident programs and their selection committees; rather,
the more likely explanation is that females and racial minority
applicants are failing to select into the applicant pool in the
first place.
STATISTICS
Gender
Figures 1A to H display 2010 Association of American Medical
Colleges (AAMC) data on residency applicants from US
medical schools, stratified by gender and specialty. Select
specialties have been chosen for comparison.11 The greatest
disparity in gender repres entation is seen in orthopedic
surgery.
Figure 2 illustrates the increase in percentage of residents
who are female within select surgical subspecialties, from
1970 to 2001.5 Note that only the field of thoracic surgery has a
slower rate of growth than orthopedics.
Race/Ethnicity
Figures 3A to H display 2010 AAMC data on residency
applicants from US allopathic medical schools, stratified by
race/ethnicity and specialty. Select specialties have been
chosen for comparison.12 Note the relative lack of racial
diversity among orthopedic residency applicants.
C
Figs 1A to C
F
Figs 1D to F
H
Figs 1A to H: 2010 AAMC data on residency applicants from US
medical schools, stratified by gender and specialty
Figure 4 depicts recent trends in the racial/ethnic compo

sition of orthopedic surgery residents from 1996 to 2009.13
Data from these years show modest improvement in racial
diversity within the field.
STRATEGY FOR THE RESIDENCY

APPLICATION PROCESS
Considering the nationwide effort to improve racial and

gender diversity in orthopedics, many consider being female
Fig. 2: The increase in percentage of residents who are female within

select surgical subspecialties from 1970 to 20015
and/or a racial minority to be a beneficial and attractive attri

bute for a medical student to possess. However, the literature
and anecdotal experience suggest that more objective
measures of ability [specifically externship performance, class
rank, United States Medical Licensing Examination (USMLE)
Step 1 score, and interview performance] are exceedingly more
important than demographics in the ranking of applicants;10
as a general rule, program directors are unwilling to comp
romise the quality of their resident compliment in order to
diversify it. To achieve success as a female or minority applicant
in the orthopedic surgery residency match, you must arguably
be just as qualified as white male applicants, as demographic
factors will not compensate for blemishes in your application.
In consideration of this, proper strategic preparation during
medical school is of paramount importance to match success,
as we highlight in other chapters of this book.
However, taking advantage of demographic circums
tances through involvement in appropriate medical, surgical,
or orthopedic societies and through seeking out personal
C
Figs 3A to C
F
Figs 3D to F
H
Figs 3A to H: 2010 AAMC data on residency applicants from US
allopathic medical schools, stratified by race/ethnicity and specialty
mentors can strengthen your application as well. Attempts

to highlight your unique personal attributes should be
pursued as early as possible during your medical school
career.
Resources Available for Female and

Minority Medical Students
Collectively known as the Trilogy Group, three orthopedic-
related societies have come together to advance diversity
Fig. 4: Recent trends in the racial/ethnic composition of orthopedic

surgery residents from 1996 to 2009.
within the field and provide guidance to women and

minorities in their pursuit of a career in orthopedic surgery.
While they are helpful in all stages of training and building
a practice, these three groups offer unique opportunities to
residency candidates. We recommend that female and/or
minority applicants become familiar with, and take advantage
of, the many options available.
The Diversity Advisory Board of the American

Academy of Orthopedic Surgeons
Fostering diversity has been named one of the key strategic
goals of the American Academy of Orthopedic Surgeons
(AAOS) and, as result of this commitment, the AAOS Diversity
Advisory Board was officially established in 1997. Since
that time, the board has been active in both recruitment of
women and minorities to the field, as well as promotion of
culturally competent care delivery within the orthopedic
surgery community. The board has established a mentoring
network specifically for minorities and females, comprising
surgeons across the country who have volunteered to advise

medical students and increase their exposure to the field.
The AAOS has also increased its visibility within the minority
medical student community through involvement at the
Student National Medical Association Annual Conference in
recent years. More information can be obtained on this
program by telephoning (847)-384-4163 or by visiting the
division’s website: http://www3.aaos.org/about/diversity/
msmentor.cfm.
The Ruth Jackson Orthopedic Society

Dr Ruth Jackson was the first practicing female orthopedist
in the US. The Ruth Jackson Orthopedic Society (RJOS)
was founded in 1983 as a support and networking group
for the growing number of female orthopedic surgeons
across the nation. It has successfully improved the lives and
careers of many women in the field through mentoring,
grant/fellowship/scholarship opportunities, scientific and
research support, and networking events. We enco urage
female residency applicants to pursue the opportunities
offered by RJOS, specifically in the areas of mentoring and
scholarship. Similar to the AAOS mentorship program
described above, RJOS offers a national network of female
orthopedists who have volunteered to partake in personal
mentorship relationships with female medical students. RJOS
also offers yearly medical student scholarships up to $1,500
provided to each of two students to attend the AAOS annual
meeting, including the RJOS luncheon at the academy.
Applications for this unique and extremely beneficial medical
student scholarship opportunity are due by early October,
and are available on the society’s website. The society has
also recently published a book entitled, “Guide for Women
in Orthopedic Surgery”, with chapters specifically for medical
students detailing how to position yourself for success as a
female orthopedic resident. More information on the RJOS
mentoring program can be obtained by telephoning (847)-
698-1626 or emailing rjos@aaos.org. General information on
the many opportunities offered by RJOS can be found on the
society’s website: http://www.rjos.org/web/index.html.
The J Robert Gladden Orthopedic Society

In 1949, Dr J Robert Gladden became the first African-
American certified by the American Board of Orthopedic
Surgery. Today, the J Robert Gladden Orthopedic Society
works as a multicultural organization founded in his honor
to meet the needs of underrepresented minority orthopedic
surgeons and to increase diversity in the orthopedic profe
ssion. The society offers many opportunities to medical
students as well: a faculty mentorship program is available,
and both student-faculty and student-resident networking
workshops are organized annually. Research grants are
periodically offered by the society as well, for which
student members are encouraged to apply. Information on
membership, mentoring, and funding opportunities can be
found on the society’s website: http://www.gladdensociety.
org/web/index.html, and questions can be emailed to jrgos@
aaos.org.
Preparation Efforts during Medical School and

the Application Process
Along with several other surgical subspecialties, orthopedic
surgery is at a relative disadvantage with regards to medical
student recruitment because it is not a required third-year
rotation at most medical schools. The student body’s lack
of exposure to the field that results may partly contribute to
the lack of diversity seen among orthopedic surgery
applicants; it is possible that only certain students possess a
reason and the motivation to proactively explore orthopedics
as a potential career path. This limited exposure may also
perpetuate myths about the field, as medical students often

fall victim to misperceptions about the male-dominated
environment, physical requisites for applicants, or the (in)
compatibility of career with family life.14
Because orthopedics is excluded from mandatory third-
year rotations, students who wish to explore orthopedics
must proactively take initiative to do so. Residency programs
recognize this, and will appreciate the demonstration of
interest in the field early on in your medical school career.
As described in other sections, we recommend seeking
out additional experience through elective rotations in
orthopedics, extra hours spent shadowing surgeons, and
extracurricular research projects; this enthusiasm to obtain
experience should extend convincingly throughout fourth-
year externships as well. It is especially important if you are
a female or minority applicant to demonstrate your sincere
attraction to the study and practice of orthopedic surgery, as
your entrance into the field is not nearly as common as that of
your Caucasian male counterparts.
As an applicant, it is important that your “story” make
sense: you must be able to articulate how and why you have
decided to pursue a career in orthopedics, and how it aligns
with your personal motivations, interests and lifestyle. Your
actions throughout medical school must be consistent with
your decision to pursue such a challenging and competitive
speciality, and you must demonstrate an understanding of
the true nature of the field. For a woman, this could mean
developing a significant mentoring relationship with a female
orthopedic surgeon, as this would demonstrate thought
and effort put toward understanding and dispelling any
myths surrounding the prospect of being a woman in the
field. If you are a minority applicant, pursuit of leadership
roles to improve cultural diversity within the surgical fields
would demonstrate reflection of the future impact you could
make on the world of orthopedics as a champion of cultural
competence. As you progress through medical school, your
story must begin to take shape, and the decisions you make
regarding time spent outside the classroom should support
your orthopedic surgery aspirations. The personal statement
section of your residency application offers an opportunity
to communicate this genuine story, and should paint a clear
picture of how and why you made the decision to pursue
orthopedics. Additionally, this is a venue for articulation of
the unique character attributes you possess as a female or
minority candidate, and how you could contribute valuable
diversity to a program’s resident complement.
Letters of recommendation are also a potential
opportunity for you as a female or minority applicant to
set yourself apart from the remaining pool of residency
applicants. Females and minorities offer unique and diverse
strengths to residency programs, and a well-written letter
can convincingly articulate your distinctive qualities. In
consideration of this, it is imperative that you seek out letter
writers who can effectively communicate your valuable
attributes, and advocate for your character traits in addition to
your academic and technical capabilities. While your USMLE
Step 1 scores, clerkship grades, and American Osteopathic
Association (AOA) membership fail to convey your character
strengths, a letter of recommendation is an avenue by which
these attributes can be glowingly expressed. It is imperative
that you take advantage of this opportunity to distinguish
yourself. Material provided to the letter writer largely dictates
the tone and content of the final letter; therefore, providing
adequate information is critical to ensuring the letter is as
personal and supportive as it can possibly be. A curriculum
vitae (CV) as well as a description of your motivations, goals,
career-defining experiences, and personal strengths should
be provided, and you should offer to meet personally with the
letter writer as well if this would allow him or her to serve as a
better advocate of the your application.
Program Selection
One of the most overwhelming questions faced during the
residency application process involves program selection,
with regards to both fourth-year externships and the Elec
tronic Residency Application Service application submission.
While some applicants have geographic or personal factors
limiting their program options, the majority of orthopedic
surgery candidates begin the process by “casting a very
wide net”. The average number of applications submitted by
students pursuing a residency in orthopedics is greater than
40—among the highest across all speciality choices.15 As you
begin the application process, ideally you will already have
achieved a level of insight into your professional and personal
aspirations, and will be able to articulate the characteristics of
a residency program that will best allow you to achieve these
goals and function as an effective resident.
Ultimately, the selection of which programs to apply to
will come down to a variety of factors, including geography,
program structure, subspecialty training strengths, rese
arch and mentorship opportunities available, overall repu
tation, and personal connections made with residents
and faculty. Female and minority applicants will also have
special considerations, such as the history of the program
with regards to minority graduates, policies fostering a
female-friendly work environment (such as maternity leave
guidelines, etc.), and the gender/race makeup of the resident
comple ment and faculty. Reputations of programs with
regards to their minority participants are not always reliable,
as the character of a program can change quickly with a new
director or the launch of new initiatives. While mentors can
provide some guidance and anecdotal perspective from
their own experience and networks, often the most accurate
impression of a program’s character with regards to minority
residents is gleaned by visiting the institution and meeting
the residents and faculty members in person.16 A month-long
visiting clerkship achieves the most truthful demonstration
of the current state of a program and its stance on minority
applicants and residents. Additionally, most residency
program coordinators can provide an applicant with the
contact information of current residents.
Interviews
The interview offers a valuable opportunity for a residency
program’s faculty members to get to know you personally,
as well as for you to continue investigating the personality of
the program. Many faculty members consider the interview
a time to answer the questions, “What will this applicant
bring to our program?” “Are you someone I would personally
want to work with for 5 years?”, and “Would I be proud to
train and be your mentor?” As a result, “getting to know you”
questions are sometimes asked, with no obvious relation to
medical training. Along these lines, women and minorities
may face unique situations during the residency interview.
While law prohibits discrimination on the basis of gender or
race, questions about ethnicity or being a female pursuing
orthopedic surgery are legal and are often asked (many
times explored through questions on marital status or plans
for family). Selection of residents based on answers to these
questions is illegal; however, discrimination does still exist.
It is helpful to view these types of questions as a chance to
evaluate the attitudes of the residency program toward female
and minority candidates; antagonistic or discriminatory
questions may be reflective of the attitudes of the program as
a whole.16
While you are not required to answer these questions,
it is important to navigate them tactfully. You can choose to
answer the question directly, or not at all, or you may ask
how it is relevant to your success as a resident in the program.
You should contemplate ahead of time how you will answer
these personal questions, and prepare an appropriate
response. If you decide not to engage in these topics of

discussion, the AAOS Diversity Advisory Board recommends
either a direct statement: “that question is discriminatory,
and I choose not to answer it,” or indirect statement: “that
subject is a private one and does not affect my candidacy
for your program.”16 It is also important to remember that
answering these personal questions truthfully is of paramount
importance; providing an insincere answer because it
“seems like the right thing to say” does a disservice to both
the program and the prospective resident. A match based on
deception and false pretences ultimately benefits no one.
When given the opportunity to ask questions during the
interview, you should be cautious when asking ethnicity or
gender-specific questions. Often times it is more appropriate
to direct these questions to female/minority residents, if you
feel a connection with the resident:
•• What is the mix of single and married residents?
•• How many ethnic minority residents are in the program/
have been through the program?
•• Do you feel welcome and accepted here as a female/
minority resident? Are you treated differently as a result of
being a woman/ethnic minority?
•• Do residents socialize outside of work together?
•• Are there policies in place concerning maternity leave?
•• Is the hospital, patient population, and local community
ethnically diverse?
Much like the letter of recommendation, the interview
is an opportunity for unique applicants to set themselves
apart. Female and minority candidates should decide ahead
of time what personal characteristics they wish to highlight
during the interview, and proactively manage the interview
to ensure these chosen attributes are emphasized during
discussion and are recognized by the interviewer. With
adequate time, practice, and mindfulness, you will realize that
interviewing is a very active task and while you are technically
the “interviewee,” the direction of the discussion is in your
hands and you can largely dictate the tone and content of the
dialogue. With this in mind, you should take advantage of this
opportunity to promote the unique and attractive traits that
you can offer a residency program as a female or minority
candidate.
CHALLENGES DURING RESIDENCY

The stressors of residency are pervasive in the lives of all
residents; however, females and racial minorities may face a
unique set of challenges. Entering the field as such a glaring
minority is stressful in and of itself. Strong mentors who
can empathize in this regard are few and may be difficult to
find, leaving female and minority residents feeling alone or
abandoned, and exacerbating feelings of being misunderstood
or discriminated against.
Stressors on Female Residents

These theories have been well-documented in medical
literature across many specialties. Female residents report
higher levels of stress, as measured by the social readjustment
rating scale (SRRS) which measures external stressors, as well
as the symptom check list 90 (SCL-90-R) which quantifies
stress-induced behaviors.17 Isolation and anxiety, loneliness
and depression, and problems balancing a family and career
are examples most often cited by the female group found to
report a higher level of stress reaction to residency. It has been
proposed that women tend to find definition in interpersonal
relationships and attachments—relationships that are not
always promoted by the residency experience.18 Functioning
in a male-dominated profession has also been shown to
further exacerbate depression and loneliness,19 and in this
context female orthopedic surgery residents may be especially
at risk given the gender inequity within the field.
Pregnancy and family-related issues have been shown

in particular to cause stress to female residents. In a study of
1,197 residents, one study found that 31% of female residents
became pregnant during residency and reported increased
stress during this time because of fatigue from frequently
being on-call, long hours, too little time for spouse or partner,
too much physical activity, and emotional strain.20 Given
the physical nature of orthopedics and the particularly long
hours associated with its residency, these stressors may
be especially taxing to female orthopedic surgeons. These
residents reported feeling support from female medical staff,
but perceived male medical staff to be “neutral at best” in
this regard. Spousal concerns may also differentially affect
male and female residents. While both genders report their
significant others to be the most influential person in their
choice of residency, female residents are more likely to
sacrifice their residency program needs for the wishes of their
partner.21 Orthopedic surgeons have one of the highest rates of
divorce across the various specialties, and female physicians
are reported to suffer a much higher divorce rate than male
physicians.22
Research has been conducted into rates of attrition
among residents, with early studies of general surgery and
orthopedic surgery residency programs finding that women
are at higher risk of attrition as compared to men.23,24 When
women withdraw, it is much more likely for family reasons
(lifestyle considerations, or to join a spouse in another
geographic location) as compared to men; when men
withdraw, it is four times more likely because of preference
for another specialty. A more recent study of obstetrics and
gynecology residents conducted in 2004 found the same
results: females were statistically more likely to withdraw
from residency programs (odds ratio 1.46, p = 0.029) and
additionally, their reason for withdrawal was statistically
more often family related.25 Many of these reports discuss the
need for stronger female mentoring within surgical residency
training, as this could potentially ameliorate the gap in
attrition rates. However, only 7.1% of the full-time orthopedic
faculty across the country are females,26 the lowest proportion
out of a selection of six specialties surveyed in one study.1 If
attrition rates are at all reflective of the contrasting scope and
magnitude of challenges faced by female and male residents,
arguably women are faced with more and broader-scale trials
during their residency.
Stressors on Racial and

Ethnic Minority Residents
Racial and ethnic minorities bring enriching and unique
perspectives to the field of medicine; however, complex social
and emotional stressors often emerge in these residents
as a result of language difficulties or cultural differences
(e.g. customs, religion, attitudes toward authority, and
methods of interaction).17 Residents raised in Asia, Europe
and Africa report increased risk of feeling reduced personal
accomplishment as compared to those raised in America or
Canada.27 While overt discrimination is infrequently reported
in the literature, incidences have been cited in which black
residents have been referred to as “you people” or called
derogatory names, black residents have been ignored in
small group teaching settings, patients have requested a
white physician, or minority physicians have been mistaken
for non-physicians at an increased rate compared to their
white colleagues.28 African-American residents interviewed
describe a sense of being the “highly-visible minority,”
differing expectations and consequences, and social isolation.
They also report a perception of blacks being punished
more harshly than their white counterparts for the same
transgression, and the expectations for their performance to
be lower.
ACHIEVING SUCCESS
DURING RESIDENCY
Developing a better and more widespread understanding

of the challenges faced by female and minority orthopedic
surgery residents will allow these individuals to achieve
greater success during residency. The orthopedic literature
shows no gender difference in performance as measured
across the Accreditation Council for Graduate Medical
Education (ACGME) competency areas;14 however, the
aforementioned discussion serves as evidence that female
and minority residents have increased barriers to success they
must overcome to achieve this level of performance. If you a
woman or a minority, you can take measures both prior to
and during residency that can help to maximize your success
during training and onwards into your career.
This effort should begin early in medical school. In general
(also applicable to white male residency candidates), medical
school academic performance is exceedingly important in
determining future residency success, with a study in 2002
finding the number of honors grades during clinical clerkship
years to be the best predictor of overall resident performance.29
The USMLE Step 1 score has also been found to be a strong
predictor of resident cognitive ability and overall success,30
and performance during orthopedic clerkship has been
associated with resident clinical evaluation scores.31
Regarding orthopedic-specific efforts, racial mino rity
and female applicants may achieve suboptimal exposure to
the field, and therefore risk holding misconceptions that could
hinder their success as a resident. To combat this, proactive
efforts must be made to increase exposure; often times this
will take the form of a strong mentorship relationship with
a faculty member, who can provide an accurate portrayal of
orthopedic practice and its accompanying lifestyle, clearing
up any stereotypes or misunderstandings about the field.
As an applicant, you must also seek out and receive sufficient
guidance during your medical school years regarding the
residency match process, as your success and personal
satisfaction as a resident is largely dependent on program-
specific factors. In this context, developing insight into your
professional and personal aspirations, and identifying the
characteristics of a residency program that would best allow
you to achieve these goals, is important in matching to the
right program and achieving future success.
Once in residency, female and minority orthopedic
surgeons emphasize the value of mentorship in determining
their success and happiness.32 Specifically, mentors who
can empathize with the personal challenges you face being
a minority resident are helpful in coping with psychosocial
burdens. While the field has far to go in establishing a more
desirable racial and gender balance across the country,
initiatives are gaining purchase in achieving this goal. If
successful, we will see growth in the number of female
and minority mentors available for the future generation
of residents, hopefully launching a self-fulfilling cycle of
recruitment of high-quality women and racial minorities to
orthopedics.
REFERENCES
1. Day CS, Lage DE, Ahn CS. Diversity based on race, ethnicity,
and sex between academic orthopedic surgery and other
specialties. A comparative study. J Bone Joint Surg Am. 2010
6;92(13):2328-35.
2. Saha S, Guiton G, Wimmers PF, et al. Student body racial and
ethnic composition and diversity-related outcomes in US
medical schools. JAMA. 2008;300(10):1135-45.
3. Reede JY. A recurring theme: the need for minority physicians.
Health Aff (Milwood). 2003;22(4):91-3.
4. Templeton K, Wood VJ, Haynes R. Women and minorities in
orthopaedic residency programs. J Am Acad Orthop Surg.
2007;15(S1):S37-41.
5. Blakemore LC, Hall JM, Biermann JS. Women in surgical

residency training programs. J Bone Joint Surg Am. 2003;85:
2477-80.
6. Magrane D, Lang J, Alexander H. (2006). Women in
US academic medicine statistics and medical school
benchmarking 2005-2006. Washington, DC: Association of
American Medical Colleges; 2006.
7. Nguyen L, Amin NH, Vail TP, et al. A paucity of women among
residents, faculty, and chairpersons in orthopaedic surgery.
Clin Orthop Relat Res. 2010;468(7):1746-8.
8. Bajaj G, Carmichael KD. What attributes are necessary to
be selected for an orthopaedic surgery residency position:
perceptions of faculty and residents. South Med J. 2004;97(12):
1179-85.
9. Scherl SA, Lively N, Simon MA. Initial review of Electronic
Residency Application Service charts by orthopaedic resid
ency faculty members. Does applicant gender matter? J Bone
Joint Surg Am. 2001;83(1):65-70.
10. Pico K, Gioe T, VanHeest A, et al. Do men outperform women
during orthopaedic residency training? Clin Orthop Relat Res.
2010;468(7):1804-8.
11. Association of American Medical Colleges. (2011). Table 39:
Residency Applicants of U.S. Medical schools by Specialty
and Sex, 2011. [online] Available from https://www.aamc.
org/download/151890/data/table39_specialtybysex2011.pdf
[Accessed May 2013].
12. Association of American Medical Colleges. (2011). Table
42: Allopathic Applicants from U.S. Medical Schools by
Specialty, Race and Ethnicity, 2011. [online] Available from
https://www.aamc.org/download/152570/data/table42-
erasrace4usallopathic2011.pdf [Accessed May, 2013].
13. Department of Research and Scientific Affairs, American
Academy of Orthopaedic Surgeons (2012). 1998-2009 Resident
Diversity Survey Report. [online] Available from http://www3.
aaos.org/about/diversity/pdfs/resident_trend.pdf [Accessed
May, 2013].
14. Stickles B. Attracting female candidates to the field of
orthopaedic surgery. J Bone Joint Surg Am. 2001;83(6):954-5.
15. Association of American Medical Colleges. (2011). Table 38:
Residency Applicants by Specialty and Sex, 2011. [online].
Available from https://www.aamc.org/download/151226/
data/table38_specialtybysex2011.pdf [Accessed May, 2013].
16. American Academy of Orthopaedic Surgeons, Diversity
Advisory Board. (2010). How to Obtain an Orthopaedic
Residency. [online] AAOS website. Available from http://
www3.aaos.org/about/diversity/pdfs/Orthoresidency.pdf
[Accessed May, 2013].
17. Levey RE. Sources of stress for residents and recommendations
for programs to assist them. Acad Med. 2001;76(2):142-50.
18. Chodorow N. Family structure and feminine personality. In:
Richardson L, Taylor V (Eds). Feminist Frontiers II. New York:
Random House; 1989. pp. 43-58.
19. Elliot DL, Girard DE. Gender and the emotional impact of
internship. J Am Med Wom Assoc. 1986;41(2):54-6.
20. Phelan ST. Sources of stress and support for the pregnant
resident. Acad Med. 1992;67(6):408-10.
21. Arnold RM, Landau C, Nissen JC, et al. The role of partners in
selecting a residency. Acad Med. 1990;65(3): 211-5.
22. Gabbard G, Menninger R (Eds). Medical Marriages, 1st edition.
Washington, DC: American Psychiatric Pub; 1988.
23. Bergen PC, Turnage RH, Carrico CJ. Gender-related attrition
in a general surgery training program. J Surg Res. 1998;77(1):
59-62.
24. Walker JL, Janssen H, Hubbard D. Gender differences in
attrition from orthopaedic surgery residency. J Am Med
Womens Assoc. 1993;48(6):182-4, 193.
25. Moschos E, Beyer MJ. Resident attrition: is gender a factor? Am
J Obstet Gynecol. 2004;191(2):387-91.
26. American Medical Association. (2009). FRIEDA Online
Database.[online] AMA website. Available from https://freida.
ama-assn.org/Freida/user/specStatisticsSearch.do?method
=viewDetail&spcCd=260&pageNumber=2 [Accessed May,
2013].
27. Afzal KI, Khan FM, Mulla Z, et al. Primary language and
cultural background as factors in resident burnout in medical
specialties: a study in a bilingual US city. South Med J.
2010;103(7):607-15.
28. Liebschutz JM, Darko GO, Finley EP, et al. In the minority:
black physicians in residency and their experiences. J Natl
Med Assoc. 2006;98(9):1441-8.
29. Dirschl DR, Dahners LE, Adams GL, et al. Correlating selection
criteria with subsequent performance as residents. Clin
Orthop Relat Res. 2002;(399):265-71.
30. Egol KA, Collins J, Zuckerman JD. Success in orthopaedic

training: resident selection and predictors of quality
performance. J Am Acad Orthop Surg. 2011;19(2):72-80.
31. Spitzer AB, Gage MJ, Looze CA, et al. Factors associated with
successful performance in an orthopaedic surgery residency. J
Bone Joint Surg Am. 2009;91(11):2750-5.
32. Flint JH, Jahangir AA, Browner BD, et al. The value of mentor
ship in orthopaedic surgery resident education: the resident’s
perspective. J Bone Joint Surg Am. 2009;91(4):1017-22.
11
Success during
Orthopedic Surgery
Residency
Kasra Ahmadinia
INTRODUCTION
After matching into an orthopedic program, you may feel a
sense of relief followed by elation. Matching into one of the
toughest fields in medicine today is the culmination of a lot
of hard work and dedication. That same dedication and drive
is needed during residency as well. As a resident, you are no
longer just “a fly on the wall” observing patient care, but you
are an integral part of the team. Attending physicians rely
on their residents to take care of day-to-day patient’s needs;
the nurses will call the resident with any questions, and the
patient will get to know you very well. This is also the time
when you will learn more than ever before. Education in
residency comes not only from books, but from conferences,
observation in the operating room (OR), and managing your
own patients. The 5 years in residency are challenging, yet
very rewarding.
INTERN YEAR
Typically, interns arrive for introductions and orientation
about a week or two before July 1 to start the year. This is when
you will learn how to put in orders, check lab results, and find
your way around the hospital. This is also a good time to get
to know your fellow residents, not only in orthopedics but in
all fields. Developing good relationships with fellow residents
will make your life easier when you have to call a consult at
1:00 am or if you just want to ask a question regarding patient
management.
Once July 1 hits, you will become very busy. Most
programs will have their interns rotate in some combination
of the following services: general surgery, neurosurgery,
plastics, radiology, anesthesiology, surgical intensive care
unit (SICU), pediatric surgery, and orthopedics. During these
rotations, you should learn two things: (1) how to manage the
patients on the floor and (2) basic surgical skills. As an intern,
you will typically have minimal OR experience and will be
called upon mostly as the first line for patient issues that arise
on the floor.
A hardworking intern will not go unnoticed. Oftentimes
the senior residents from the different services will talk with
the senior orthopedics resident about how the intern is doing
on that rotation (remember how it was good to make friends
with residents from other services). Oftentimes, residents
who get a bad reputation develop it during their intern year.
They think that since they are not on their “home” service, it
does not matter how they are perceived. Again, this is far from
the truth. Word travels fast in the hospital and your senior
residents in your “home” program will find out about any bad
behavior and so will the attending physicians.
What Makes a Good Intern?

It all starts with rounds. It is always a good rule to be at the
hospital before the next more senior person shows up.
So, if you are on a service and they decide to do rounds at
6:00 am, the successful intern will be there at 5:30 am. During
that extra 30 minutes, you will be able to do pre-rounds on
Success during Orthopedic Surgery Residency 131
the patients and discover if there were any issues overnight
that need to be addressed. As the intern, you should try to
know more about the patient than any other member of the
team. You should have all vital signs gathered and even begin
to draft the notes for the day. This way, when the rest of the
team arrives rounds can start right away. This tactic will be
very much appreciated because it will allow rounds to start
slightly later (which means extra sleep!). During rounds, a
good intern will also have all the dressing supplies needed for
dressing changes. On many services, dressings are changed
during morning rounds, and this can be very time consuming.
Have the dressing supplies on hand can significantly decrease
the time needed for rounds. Once rounds are finished, the
intern is typically responsible for following up to make sure
that everything discussed on rounds happens (labs ordered,
discharges planned, consults called, etc.). Again, the intern
has typically the eyes and ears on the floor, while the team is
in the OR. If questions arise, you should not hesitate to find a
senior resident and ask for help. Everyone expects you to work
hard, but no one expects you to know everything. Finally, as
the end of the day approaches, a good intern will have tied up
all loose ends and will have prepared a good sign-out report
for the night team.
Keeping up with all the responsibilities during intern year
can be challenging. A successful resident is not necessarily the
smartest resident, but the most organized. Having a to-do list
is essential during your intern year. Populating the list during
rounds will remind you of what needs to be done and what to
follow-up on. Another challenge is, knowing when to ask for
help. As an intern, you will be faced with numerous scenarios
that you may have never experienced before. While there is
something to be said about being independent, it is important
to remember that you are now responsible for patient care.
If you have any questions, make sure to ask the more senior
residents.
Aside from clinical responsibilities, it is important that

you keep up with your education. In residency, learning is
oftentimes self-directed. You would not be assigned chapters
to read or have quizzes and tests like you did in medical
school. The attending physicians and senior residents expect
that you are keeping up with the necessary reading. As an
orthopedic resident, it is important to read not only for the
service you are rotating on, but also for orthopedics. A good
introductory book on orthopedics and an anatomy book such
as Netter’s Atlas of Human Anatomy are important to review
when you can.
Finally, aside from clinical duties and education, it is
imperative to maintain your own mental health. You will
spend a significant amount of time at the hospital working,
but there will also be free time. Make time to do things that
you enjoy doing but that are unrelated to work. There will also
be plenty of opportunities to interact with other residents
outside of the hospital and at many social gatherings. If you
have a significant other, make sure to spend time with him or
her and talk about something other than work. Unless they are
also in medicine, your significant other might not find the fact
that you placed your first nasogastric (NG) tube as exciting as
you might think.
Characteristics of Successful Interns

•• First to arrive and last to leave
•• Knows the patients better than anyone
•• Prepared for rounds
•• Knows when to ask for help
•• Able to separate work life from home life.
JUNIOR YEAR
After completing your intern year, you will be solely focused

on orthopedics. Unfortunately, you will graduate from the
lowest on the totem pole in the hospital to the lowest on the
totem pole on the orthopedics service. For most residents,
the postgraduation year 2 (PGY-2) is the most challenging.
During this year, you will be fully immersed in the orthopedic
world, and oftentimes it will feel like you are learning a new
language. A lot of expectations from intern year will also be
there during the PGY-2 year. Again, you will be expected to
manage the issues on the floor; however, there will be more
OR experience as well. Being able to manage both aspects is
very time consuming and stressful, but when you look back
on this year; it is also the most rewarding. You will learn more
during your PGY-2 year than you probably have during any
other year in your education.
What Makes a Good Junior Resident?

Being a good junior resident also begins with rounds in the
morning. The rule of being there before the next most senior
resident will still hold true. If there is an intern on service,
then they will typically take care of pre-rounds; otherwise the
responsibility often falls on the most junior resident. Obtai
ning vital signs and speaking to the nurses regarding issues
that occurred overnight will become second nature for the
junior resident. The pre-rounds time may seem tedious, but it
is very important in preparing you for the day. By speaking to
the nurses and doing a chart check for any overnight events,
you will be well versed on patients’ status by the time formal
rounds start. This will build the trust of your senior resident,
which will lead to greater autonomy during your rotation.
Following rounds, the surgical cases are divided up
among the team. As a junior resident in orthopedics, you
may be assigned to a patient for the day. Prior to going into
the OR, it is very important that you familiarize yourself with
the patient. This often starts the night before with a thorough
chart review. Knowing the patient’s disease or disorder and
understanding the attending physician’s thought process for
indicating surgery will allow you to gain the most from the
experience in the OR. Oftentimes, the chart review will help
you understand how the patient’s medical history dictates
the operative technique utilized. A well-prepared resident
will have also reviewed the relevant anatomy as well as any
necessary technique guides for the operation. At this level in
your residency, most attending physicians and senior residents
do not expect you to know everything about orthopedics.
However, they do expect that you are reading and preparing
yourself to treat patients, and the easiest way to test that is with
anatomy questions. Anatomy is the foundation of orthopedics
and is also a convenient way to figure out how prepared a
resident is. On the morning of surgery, it is important to meet
the patient and do a thorough examination as well as review
the preoperative lab values. The preoperative examination is
needed in order to observe any changes postoperatively. It is
never a good idea to go into surgery unprepared regarding the
patient’s history, surgical anatomy, and implant techniques.
In terms of education, the junior resident year is the
best time to learn the language of orthopedics. This allows
you to efficiently communicate with the senior residents
and attending physicians regarding patients. Daily reading
is essential for advancing your education. A good textbook
on trauma and a general orthopedics textbook such as
Campbell’s Operative Orthopedics help build a good found
ation. Another good resource is the Journal of the American
Academy of Orthopedic Surgeons (JAAOS). This journal
includes review articles that are directed for resident-level
education. Reading textbooks and journals introduces you to
the language of orthopedics, but the best strategy is practice.
Use every opportunity to do consults and work-up patients,
but most important learn to present patient’s cases to senior
residents and attending physicians.
Participating in consults is also an integral part of
the junior years. Most programs have junior residents take
front-line calls and therefore you will inevitably receive
numerous consult requests on each call day. While consults
can be frustrating and time consuming, you should view
them as a learning opportunity. Learning how to take a good
history will help with narrowing your differential diagnosis
and tailor your diagnostic plan. Being able to perform a good
physical examination is integral for the orthopedic surgeon.
Many diagnoses can be made just by taking a good history,
performing a thorough physical examination, and confirming
results with diagnostic imaging. As a junior resident, you
should use these consults to hone your history taking and
physical examination skills. It is never a good idea to seek
a consultation with a bad attitude or to be condescending
to those who are consulting you. No matter how ridiculous
the consult seems, it is someone asking for your help. Also,
if you treat people inappropriately, your program director or
chairman will hear about it and then you will hear about it.
You will also spend time in the clinics during your
junior years. This is an opportunity to see how the attending
physicians interact with the patient and how patients with
various disorders present. Learning how to interact with
patients is critical for a successful career. As a junior resident,
part of your time in the clinic should be spent observing the
doctor-patient interaction. You will pick up small nuances
from each of your attending physicians, which will help you
develop your own style. Observation will also help you learn
proper history taking and physical examination.
Characteristics of a Successful Junior Resident

•• Comes to the OR prepared for the case
•• Able to manage the floor and participate in surgeries
•• Keeps up with daily reading
•• Able to communicate with senior residents and attending
physicians.
SENIOR-LEVEL RESIDENT
As a senior-level resident, you will finally see the light at the end
of the tunnel. You have developed the foundation for a career
in orthopedics and are now starting to develop and hone your
skills. Clinically, you are one of the leaders of the team. You
determine when to do rounds and what needs to be done
during rounds. The senior resident is often the bridge between
the attending physician and the patient. It is important to
know the overall plan for each patient and to assign roles for
each team member. More importantly, the senior resident
must make sure that everyone is doing what they are supposed
to be doing. You cannot assume that if you asked your junior
resident to follow-up on a lab value that it will always get done.
Oftentimes, afternoon rounds (doing a quick chart rounds
before the day is done) can be beneficial in determining what
happened during the day and what needs to be done the
following day.
While the senior resident is generally in charge of
overseeing the floor work, his or her main focus should
be on the OR. These are the years where more and more
responsibilities are given to the resident in the OR. It becomes
even more important to have a thorough understanding
of each patient’s case. The night before surgery should be
spent doing preoperative planning if possible. This includes
reviewing the relevant anatomy, understanding the surgical
approach, and feeling comfortable with necessary equipment.
X-rays and advanced imaging should all be reviewed and
incorporated into the preoperative plan. By the time you
step into the OR, you should know exactly how to proceed
and also have options for when the unexpected happens. If
you are well prepared before coming to the OR, the attending
physicians will trust you and you will be able to participate
more in the surgery. The worst case scenario is walking into
the OR unprepared, as this shows the attending physicians
that you are not ready to operate.
While developing your surgical skills is important,
understanding the indications for surgery is what truly sets
apart a good surgeon from an average surgeon. In the field of
orthopedics, we often think, “if it is broken, I can fix it”. This
philosophy is simple but not always applicable. The true art
of orthopedics is determining which patients need operative
intervention and what kind. When the attending physician
decides to operate on a patient, he or she has spent many
clinic visits attempting to understand the patient’s pathology.
After completing histories, physical examinations, diagnostic
imaging, etc. the attending physician can come up with a plan
that best benefits the patient. Understanding the indications
for surgery is fundamental. As the senior resident, you
should try to speak with the attending physician before the
operation to understand why surgery is indicated. Could this
patient have been treated nonoperatively? Are there different
techniques or approaches that could have been used? Asking
such questions in a tactful way will show the attending
physician that you are interested in the patient and that you
have spent time thinking about the indications for surgery.
You can also learn to determine indications for surgery
in the clinic setting. As a senior resident, you spend time in
the clinic not only to learn physical examination maneuvers,
but also to develop differential diagnoses and solidify surgical
indications. With each patient, you should have a diagnosis
in mind and a treatment plan in place. You can then review
this plan with your attending physician and discuss other
potential options. By doing this, you will hopefully learn
proper indications for surgery, and hence have better results.
Another important responsibility for the senior resident
is to be a teacher. Junior residents will look up to their senior
colleagues for guidance. As a senior resident, you should set
aside time to teach the junior residents about orthopedics.
One way to teach is to go over each patient’s case for the next
day as a team. This allows for discussion regarding indications
for surgery, anatomy, and technique. Afternoon rounds can

also be a good time to discuss the patients on the floor and
why certain tests were ordered. Taking the time to teach junior
residents will help to foster a team atmosphere and will make
the working environment a pleasant one. It will also help
garner the respect of the junior residents. A true team player
is not only concerned with the people above him, but for his
entire team.
Resources
Whether you decide to pursue a fellowship or go straight into
practice after residency, it is important to start immersing
yourself in the literature. During the junior years, you build
a foundation by reading textbooks. You learn the generics of
orthopedics and learn the language. As a senior resident, you
start to build on that foundation by reading journal articles.
The benchmark journal in orthopedics is the Journal of
Bone and Joint Surgery (JBJS), which is published biweekly.
It is important to review these journal articles when you can.
Journal articles can help you refine your process of making
surgical indications and have evidence for your preoperative
plan. Keeping up with the literature can be daunting initially
but it is crucial to understand which studies are important.
The AAOS website also has a section for resident education
with presentations and clinical topics written by experts in
the field. These are broken into categories and provide a good
overview of various topics.
Characteristics of a Successful Senior Resident

•• Team leader and leads by example
•• Well prepared for the OR
•• Enters each case with not only a plan A, but also a plan B
and C as well
•• Good teacher for the junior residents.
SPECIAL TOPICS DURING RESIDENCY

Tests
Each year during November, all orthopedic residents around
the country participate in the Orthopedic In-Training
Examination (OITE). This test consists of over 200 questions
on orthopedics and is taken over several hours. The intention
of this test is to determine areas of strengths and weakness
across the field of orthopedics. The test is scored with a raw
score and the resident’s percentile with regards to his or her
own level of training, as well as all residents, is reported.
Studying for this test is an ongoing process. Most of the
knowledge needed for this test comes from regular reading
and adequate preparation for patient cases. The AAOS also
has a number of helpful resources for preparation for the
OITE. These resources include a question bank that includes
former OITE questions, as well as self-assessment exams
(SAEs). The SAEs consist of OITE-like questions, and the AAOS
publishes questions for three different subspecialties each
year. Oftentimes your program directors will buy the SAEs,
but if not the AAOS provides a discounted rate for residents.
Different programs place varying emphasis on this
test. For some programs, this test is used solely for residents
to determine areas in which they are weak so that they can
focus on that particular area during their studying. Other
programs place greater emphasis on this test and structure
their didactic curriculum around this test. It is important to
determine how much emphasis your program places on the
OITE and tailor your preparation for this test accordingly.
In a recent study published in JBJS, it was determined that
there was a correlation with OITE percentile rankings and the
passing rate on the orthopedics board examination. The only
significant results with regards to passing the boards were the
percentile rate in the fifth year, and overall 4-year percentile
rank (greater than 30th percentile).
While the OITE itself will not directly affect you during
your residency period, it does help predict who will pass
the board examination following residency. The board
examination is a test that requires adequate preparation
and will directly affect your career in orthopedics. Most
hospitals will require a passing score prior to offering
credentials to their physicians. Failing this exam, which
is given once an year, may delay your career and have a
great psychological impact. For this reason, most senior
residents spend the majority of their PGY-5 year preparing
for the examination. Many resources, including board review
books and courses, can help you to prepare. Most senior
residents have a copy of either Miller’s Review of Orthopedics
or the AAOS Comprehensive Review of Orthopedics. These
books are organized by subspecialties and provide a thorough
overview of orthopedics. It is advisable to set up a study
schedule to follow during the PGY-5 year and the review
books can be used as guide for this schedule. Most residents
also take a review course during the spring of their PGY-5 year.
Two of the main review courses are the Miller review course
in Denver and the AAOS review course in Chicago. Usually,
your program will set aside funding for one of these courses
because they can otherwise get pretty expensive.
One big difference between the board examination
and the OITE is the quality of questions. Because the board
examination is actually used by hospitals and is used for
credentialing, there must be a clear right answer to the
question. The process of selecting questions for the board
examination is stringent and there must be consensus on a
correct answer. Most of the questions will have answers that
can be clearly supported by the literature, so keeping up with
journal reading will greatly enhance your familiarity with the
subject matter. The OITE on the other hand does not have as
stringent a question selection process. Oftentimes roughly
5–10% of the questions are thrown out because a clear
answer is not evident. Also, they may use questions as
indicators of practices around the country (for e.g.) whether a
surgeon would use a dynamic hip screw or a cephalomedullary
nail for the treatment of an intertrochanteric femur fracture).
FELLOWSHIP PLANNING
Given that the field of medicine is becoming more specialized,
a greater percentage of orthopedics residents are choosing to
specialize further by doing a 1-year fellowship. If you do not
know whether you want to specialize when you first arrive
at residency, do not worry. Most people do not know which
specialty they will apply (if any at all) until their third year.
By that time, you will probably have had a chance to rotate
in each subspecialty, and will have a feel for what types
you enjoy doing. The choice of whether to do a fellowship
and which one should be solidified by the end of the
third year or beginning of the fourth year at the latest.
Currently, all subspecialty fellowships are determined by a
match process much like getting into residency. Applications
are typically due between October and December depending
on the specialty. Interviews are conducted during the winter
and early spring, and by May of the fourth year you will know
the result of the match process.
To prepare for the application process, you should start
working on the application as soon as you know that you
are going to apply to a fellowship. You will need to work on
a personal statement and also secure three or four letters of
recommendation. Asking for letters early in the process will
ensure that you get them on time, as attending physicians are
often busy and may take some time to write your letter. If you
know early that you want to specialize in a particular field, it
may be beneficial to work on research pertaining to that field.
This serves two purposes. First, it allows you to enhance your
resume, particularly if the research leads to presentations or
publications. Second, it helps you develop a relationship with

an attending physician in the field, which will lead to a more
sincere letter of recommendation.
RESEARCH
Doing research during residency is not for everyone. Many
people do not like research and do not want to participate
in any form of research if they do not have to. This is okay.
Most residencies have requirements for a senior project, but
you have 5 years to come up with one project. Others enjoy
the process of discovery and want to pursue research. While
research does take time and effort, there are benefits that
come with the process. If you have any inclination of joining
an academic practice, then understanding the research
process is paramount. Academic institutions will require their
attending physicians to produce research on a regular basis
and those who do not will not thrive in that environment.
Many fellowships are also based out of academic institutions
and often require research from their fellows during their year
there. They therefore prefer, but do not require, applicants
with research experience.
If you decide to do research, you should start early in
residency. Even if you do not know what specialty you are
interested in, you can still start research with a mentor. Most
projects will either be in basic science or clinical research.
Each type has its pros and cons. Basic science research does
not require institutional review board (IRB) approval and
therefore will not be held up by a committee. These projects
can be expensive though, and it would be necessary to either
secure a grant or join a lab that already has funding for you.
Basic science research requires a particular skill set that may
be difficult to pick up if you do not have prior experience.
Also, lab work can be very time consuming. You will need to
run experiments that may need significant amounts of time,
which you may not have. In terms of publication, basic science
research in orthopedics is very valued. Each JBJS publication
has two or three basic science articles.
If you do not have the time or expertise for basic science
research, clinical research is a good alternative. The ideal type
of research is a randomized controlled trial. However, this type
of project can take many years to obtain publishable results
and requires IRB approval. Oftentimes, you can get quick
projects done by doing chart reviews. These retrospective
reviews are not as powerful as randomized controlled trials,
but if the topic is well chosen, they can be just as interesting.
These also require IRB approval, but the actual process
does not take as long and can be completed within weeks
depending on the sample size. Attending physicians are
usually very open about helping residents with research and
will be happy to allow you to review their charts for a project.
If you decide to do research, a few steps can help make
you successful. First, it is always impressive to your mentor if
you present a research idea to them rather than asking them for
an idea. These ideas can be inspired by research projects that
have already been published or through novel experiences.
Each surgical case that you participate in can be a potential
source for a research idea. If you see, your attending physician
doing something that is different from what you learned in
the textbook, you can ask if this is something they came up
with or if they do it based on published results. If they came
up with this technique, then ask if they would be interested in
looking at their results compared to the traditional method.
Another source of idea is patients who return to the clinic with
complications. Every orthopedic surgeon wants to reduce
complication rates, and a retrospective chart review can help
identify patients at risk for complications. If you have trouble
coming up with ideas initially, it is okay to ask to join a project,
but always keep your eye out for new ideas or questions that
need to be answered.
Another quality of a successful researcher is establishing

deadlines and sticking to them. Unlike in college or even
medical school, there are no hard deadlines that are set by a
teacher in residency. Your research mentor will trust that you
will only undertake a project that you can complete in a timely
manner. You should set deadlines for yourself, including
when you will complete data collection, when the statistics
will be completed, when the abstract will be completed,
and when the manuscript will be completed. A resident
who has deadlines and meets them is very well regarded
and appreciated. Deadlines can be made in correlation
with abstract submission guidelines. You may submit your
abstract to various conferences as long as they have not been
submitted to the conference in the past. Getting abstracts
accepted at national conferences is an honor for you and your
residency program. As such, many programs will help pay
for registration and travel if your abstract gets accepted for
presentation.
Presenting at national conferences is not only a great
addition to your resume, but also a way to network with
the leading physicians in the field of orthopedics. If you are
fortunate enough to present your research at the academy
meeting in the fall, then your work will be seen by thousands
of orthopedic surgeons in the country. Oftentimes this can
lead to collaboration opportunities with others who share
your idea or are intrigued by your results.
CONFERENCES AND SKILLS

LAB DURING RESIDENCY
Many educational opportunities that you can take advantage

of exist outside your hospital. One of the most well attended
courses is the AO Basic Course. This course is run by the AO
foundation and typically has a great faculty, most of whom
have specialized in orthopedic trauma. During this course,
you learn the basics of traumatology and the biomechanics
behind the implants that are used. Each day begins with
lectures and is followed by hands-on training in the afternoon.
Supervision by an orthopedic traumatologist is one aspect of
this course that sets it apart from other courses. This 4-day
course is offered multiple times during the year. Every other
year this course is offered in Marco Island, Florida, and is
slightly longer with the afternoons mostly free.
Another conference that is beneficial to attend at least
once during residency is the academy meeting. This meeting
is the largest meeting in orthopedics and every specialty is
represented. At the academy, you can attend the instructional
course lectures (ICLs), which cover a vast array of topics in
all subspecialties. These are taught by leaders in the field and
can also be a great way of networking. The academy also offers
skills labs, which are supervised by leaders in the field. This is
a great opportunity to try out new techniques and implants.
You can also see the newest equipment at the vendors’ area.
At the academy meeting, the exhibition hall is very large,
and each company has a booth set up with multiple sales
representatives.
You can also attend courses that are sponsored by
vendors. These courses are often not continuing medical
education (CME) accredited, and you should check with
your program director regarding being able to attend these
courses. These can be very informative and beneficial to your
education. You will be able to test out new equipment while
also honing your surgical skills often on cadavers provided
for the course. If interested in attending these courses, contact
your hospital representative and ask for a list of courses
available for the year.
12
Orthopedic Fellowship
Application Process
Antonia F Chen
INTRODUCTION
Choosing to do an orthopedic fellowship after residency is
an optional educational opportunity. After completion of
an accredited orthopedic residency, all residents should be
able to perform general orthopedic surgery. However, more
individuals are opting to do a fellowship after residency,
especially given the recent trend toward specialized medicine.
All accredited fellowships are a minimum of 12 months.
Individuals commonly begin the fellowship application
process during their second to last year of residency, which is
often during postgraduate year-4 (PGY-4) of residency.
There are eight subspecialties in orthopedics that offer
orthopedic fellowships: adult reconstruction, foot and ankle,
hand, pediatrics, spine, sports, trauma and tumor. Over the
last few years, the fellowship application process has utilized
the match system similar to residency, where individuals and
programs submit rank lists and on Match Day, individuals
are paired with one program. The match program is specific
to each subspecialty group. For example, the American
Association of Hip and Knee Surgeons (AAHKS) and the
Musculoskeletal Tumor Society (MSTS) combined to offer
fellowships for arthroplasty or orthopedic oncology; the

American Society for Surgery of the Hand (ASSH) offers
fellowships for hand; and the American Orthopedic Society
for Sports Medicine (AOSSM) and Arthroscopy Association of
North America (AANA) combined to sponsor the match for
sports medicine.
All of the orthopedic fellowships, except for those in
hand, are conducted under the San Francisco (SF) Match
system. This system is also used for the neurology, ophthal
mology, and plastic surgery residency match, as well as the
adult cardiothoracic anesthesiology, craniofacial, facial
plastic, neurocritical care, neurosurgery, ophthalmic plastic
and reconstructive surgery, ophthalmology, pediatric derma
tology, pediatric otolaryngology, Mohs, and rhinology
fellowships. Hand fellowship applications are processed by
the National Resident Matching Program (NRMP), under
the specialties matching services, specifically known as the
Combined Musculoskeletal Matching Program (CMMP),
where plastic surgery and orthopedic residents can both
apply for a hand fellowship.
For a number of years, the orthopedic fellowship oper
ated independent of the match system. Applicants would
submit applications to individual fellowships and positions
as openings would be offered at various times of the year;
some fellowship positions were offered as early as the end
of the PGY-3 year. Although departure from the traditional
method to the match system for orthopedic fellowships was
first met with wariness, the benefit of the match has been seen
over recent years in that it allows applicants to fairly evaluate
every program prior to making a decision, since fellowship
positions are offered at the same time. Additionally, it permits
programs to assess more applicants before rank lists are due.
While there are pros and cons to implementing the match
system, the purpose of this chapter is to review key aspects
of the orthopedic fellowship application process. Topics that
Orthopedic Fellowship Application Process 149
are covered include choosing where to apply, the application
process, selection criteria used to evaluate applicants,
interviews, creating a rank list, and the matching process. It
is our hope that the advice in this chapter will help you with a
successful fellowship application.
CHOOSING WHERE TO APPLY

You should consider many variables when choosing fellow
ships to apply to. Given the match process, applicants have
been applying to more programs to ensure that they match.
In general, it is advisable to apply to a minimum of five
programs, with a maximum of 12–15. The number of programs
you should apply to is based on the competitiveness of each
field and on your individual preferences.
Each orthopedic subspecialty differs in competitiveness.
Recently, the most competitive fellowships include hand and
sports medicine. For hand, there were a total of 78 programs
with 162 available positions. For sports medicine, there
were 93 programs that had 219 fellowship positions. There
were 59 programs in adult reconstruction, 80 programs in
orthopedic spine, and 55 programs for orthopedic trauma.
For a competitive subspecialty, we advise you to apply to more
programs to increase your chance of matching. Additionally,
you may apply to more than one orthopedic fellowship, but
once you successfully match to an orthopedic specialty,
your application is automatically withdrawn from all other
specialty matches.
Besides the competitiveness of a certain subspecialty,
most factors that will determine which programs you apply to
are all personal choice. There are many factors to consider for
fellowship applications, but the main ones are as follows:
•• Hospital setting
•• Research
•• Geographic location
•• Reputation of a program
•• Operative experience
•• Nonoperative experience
•• Size
One of the main points of stratification of fellowship
programs is whether or not the program is affiliated with a
residency program at a teaching hospital (academic fellow
ship), or if the program is affiliated with a private practice.
Academic programs generally emphasize formal teaching,
conferences, interaction with a variety of attending physicians,
and mentoring residents. Fellowships at private practices often
do not have residents and commonly have fewer attending
physicians, which allows you to concentrate on developing a
mentoring relationship and may permit you to learn specific
techniques more in depth. Determining how residents and
fellows share responsibilities may be an important deciding
factor for choosing a program. Individuals who are interested
in pursuing a career in academic orthopedics often apply
to academic programs, while those who are interested in
private practice often opt for the private practice fellowships.
However, there is a great deal of crossover between the two,
as more private practice fellowships may work with residents
and have involvement in research conferences, and some
academic fellowships are actually private practices that are
associated with teaching hospitals.
Another factor that differentiates most fellowships is the
exposure and expectation for conducting research projects.
Some fellowship programs have a research requirement,
which can be quantified as a percentage of time, the number of
projects that should be undertaken throughout the fellowship
year, or the number of publications that should be completed at
the end of the fellowship year. Some programs offer dedicated
time off to conduct research (e.g. 1 day a week for research
projects), while other programs expect individuals to conduct
research in addition to clinical duties. There are two main
areas of research: (1) basic science and (2) clinical research.
Most programs have requirements for clinical research; basic
science research requires access to laboratory space, and is
commonly conducted in academic institutions. Additionally,
basic science research often requires more dedicated time
to perform experiments, and it may be difficult to complete
a project within the 1-year time frame of a fellowship. Some
fellowships, especially fellowships in orthopedic oncology,
encourage adding one more year of fellowship to complete
basic science research projects. In addition to evaluating
a program’s research requirements, it is also important to
assess a program’s infrastructure for conducting research. For
example, it is helpful to have funding available, a librarian to
help with literature searches, a statistician to help perform
statistics associated with research projects, and research
fellows, medical students, and residents to help conduct
studies. However, even if all these resources are available,
your interest in research will determine what programs would
be a good fit.
Aside from the structure of the program, the geographic
location of a fellowship may play a big role in deciding
where to go. Geographically, programs are clustered into the
following groups: East coast, West coast, the Midwest and
the South. Applicants often state that proximity to family
is an important factor for determining a fellowship choice.
Some applicants establish roots during residency that make
it difficult for them to leave a particular region; thus, it is
natural for these applicants to look for fellowships near their
residency location. Some fellows eventually procure jobs near
the location of their fellowship.
The reputation of a program can play the biggest factor
in choosing a program. Some fellowships are accredited by
the Accreditation Council for Graduate Medical Education

(ACGME) and some are not. In order to be ACGME accredited,
certain criteria must be met and documentation must be
routinely followed up. You should determine whether or not
it is important to attend an ACGME-accredited program.
In addition to accreditation, some fellows choose a parti
cular institution in order to work with specific attending
physicians, either for their clinical skills and/or their research
interests. Certain attending physicians may be known for
surgical procedures that you are interested in learning, and
attending this institution as a fellow would provide a good
opportunity to become proficient at these techniques.
Operative experience is a key part of deciding on fellow
ships, as fellowship applicants are surgeons who want to learn
how to better perform surgery. Residents often cite operative
experience as the major reason that they choose to complete
a fellowship, either because their program was lacking in a
particular subspecialty or they feel that a fellowship would
enhance their surgical experience in a particular subspecialty.
The purpose of completing a fellowship is to gain a varied
surgical experience within a certain subspecialty with a
sufficient caseload so that you may obtain the necessary skills
to practice on your own.
There are a few key differences in programs, with
regard to volume, variety of cases, and the amount of hands-
on experience you will gain. Some programs have a very
high volume of cases, which is good for gaining as much
surgical exposure as possible, but may dilute the amount of
time spent with each attending physician learning specific
procedures. The best way to determine the volume of surgery
at an institution is to ask current and past fellows how many
operations they performed during their fellowship year.
Another operative experience consideration is the type of
operations that are performed. Some programs perform more
complex revision procedures, while other programs focus
on primary procedures. Certain fellowships offer a variety of
procedures, while other programs focus on a few procedures.
For example, in arthroplasty, all fellowships perform primary
and revision hip and knee arthroplasties, but some fellowship
programs offer more surgical cases on unicondylar knee
arthroplasty, robotics, hip resurfacing, periacetabular osteo
tomies, and hip arthroscopies. If these kinds of procedures
are of interest to you, then you should highly consider these
programs. Additionally, different surgical approaches may
be performed at different institutions. Again, for total joint
arthroplasty, different surgical approaches may be of interest
to applicants, such as the posterior, modified Hardinge
(lateral decubitus or supine), and direct anterior approaches
for the hip, and a medial or lateral parapatellar arthrotomy
for the knee. Finally, the amount of hands-on experience is
important in considering a fellowship. In some programs, the
fellows will perform the majority of operations, while other
programs have certain rotations where fellows perform less
of the surgery. Often, the choice of fellowship depends on
your surgical experience during residency; if you had a strong
operative experience, hands-on time in the operating room
may be less important than learning new surgical techniques.
Conversely, if you had less operative time in residency, you
may be more interested in a fellowship that allows fellows to
gain more hands-on surgical experience.
While a good operative experience is important, the
nonoperative experience, or clinical experience, is equally
as important. Clinical work is necessary for learning how to
evaluate patients, how to counsel patients, and to develop
your clinical decision-making skills. Learning how to run a
practice and the nuances of billing and coding are experiences
learned during a good clinical experience. The key is to find
a fellowship that balances between clinical and operative
responsibilities. Too much clinical work will hinder a good
surgical experience, while only spending time in the operating
room will prevent you from learning how to evaluate patients

once you become an attending physician.
Finally, the size of a program may be a factor to consider
when choosing a fellowship program. Most programs have
1–3 fellows per year. The benefit of a smaller fellowship is
that there is often a stronger mentorship component to
the program, there are opportunities to repeat rotations to
reinforce learned surgical techniques, and there may be
more opportunities to select operative cases to cover. On
the other hand, larger programs (4–8 fellows) allow fellows
to experience a larger variety of attending physicians and
procedures, help with distributing responsibility (e.g. call),
and allow the fellows to build camaraderie within a larger
group of individuals. Both options have pros and cons, and
your choice depends on personal preference, as with most of
the criteria presented in this section.
APPLICATION PROCESS
The orthopedic fellowship application process is similar to the

residency application process in many ways, with a specific
focus on one of the subspecialties in orthopedics. For the SF
Match, applicants initially upload a central application service
(CAS) application. The CAS application consists of personal
information (contact information), education and training,
military service, licenses and examinations, a personal state
ment, and the contact information for the individuals writing
the letters of recommendation. This application is also
accompanied by a small, nonrefundable registration fee to
cover registration and matching. Additionally, there is a fee for
participating in the CAS service; as the number of fellowship
program applications increase, the fees also increase. For
application to 1–10 fellowship programs, the fee is $60. For
application to 11–20 programs, there is an additional $10 fee
per program over 10 programs. Applying to 21–30 programs
is an additional $15 per program, applying to 31–40 programs
is an additional $20 per program, and applying to 41 or more
programs costs $35 per program.
The remaining documents must be gathered together
and submitted as one package to the SF Match: medical school
transcript(s), United States Medical Licensing Examination
(USMLE) scores (or equivalent), educational commission
for foreign medical graduates (ECFMG) certificate, three
letters of reference, and an updated curriculum vitae (CV or
resume). For the SF Match, only two support documents may
be added to the application: (1) a prior residency completion
certificate and (2) a foreign specialty program certificate.
Other documents that may be requested by specific programs
should be mailed directly to the requesting program.
For all applicants, an official or copy of the medical
school transcript must be included. If you attended more
than one medical school, transcripts from each school must
be provided. For international medical graduates (IMGs), a
medical school transcript must be submitted in English. If a
translated copy is submitted, then it must be professionally
notarized. Additionally, IMGs must also include the ECFMG
certificate when applying for fellowship.
Copies of original examination score reports from offi
cial examinations [USMLE Step 1, Step 2 and Step 3, National
Board of Medical Examiner (NBME), federal licensing
examination (FLEX) or visa qualifying examination (VQE)]
must also be included in the application. The SF Match
requests copies of the performance profile pages on the back
of USMLE Step 1, Step 2 and Step 3 original score reports, but
it is not mandatory to provide these. If a copy of an original
score report is not available, you must request a transcript for
the specified examination.
The three letters of reference should all be original and
should come from individuals who have worked closely with
you and know you well. When addressing letters, there is no
standard salutation. Most letters will be addressed as “Dear

Program”, “Dear Program Director”, or “Dear Colleague”. It
is highly recommended that one of the letters should come
from the Residency Training Program Director or the Chair
person of the program. You have the option of keeping
letters confidential or not. If you request a confidential letter,
this must be indicated on the CAS application, and letters
should be placed in sealed envelopes and then mailed in. If
it is difficult to obtain an original letter of recommendation
(especially for IMGs), it is acceptable to submit a copy, but
letters should be marked as a “copy” and translated letters
must be professionally notarized.
There is a recommended format for submitting a CV.
No pictures should be submitted with a CV. The sugg
ested format is as follows: name, degrees, date, contact
information, education, postgraduate education and trai
ning, certifications, medical licensures, military service,
professional society memberships, honors and awards,
team coverage experience, administrative services, local and
national service, grant support, research experience, presen
tations, and publications.
The SF Match differs from the CMMP process because
it is a centralized, online application process. Through the
SF Match, you only need to submit one common application
when applying for fellowships. From that point, programs
contact applicants individually and offer or decline interviews
for fellowship positions. On the other hand, for hand
fellowships, you should contact program directors directly
and request specific fellowship applications. Applications
must be completed for individual programs and mailed
separately to each institution.
For the application process, here are some key websites
that may be helpful:
SF Match (for fellowship): Step by step instructions are
available on the website http://www.sfmatch.org/index.htm,
along with a training video.
NRMP Fellowship Match (CMMP): http://www.nrmp.
org/fellow/match_name/cmmp/about.html
Adult reconstruction and Musculoskeletal Oncology: http:
//www.sfmatch.org/fellowship/f_hipknee/index.htm
Foot and Ankle: http://www.sfmatch.org/fellowship/f_
ofa/index.htm
Pediatrics: http://www.sfmatch.org/fellowship/f_p edor-
thopaedic/index.htm
Spine: http://www.sfmatch.org/fellowship/f_spn/index.
htm
Sports: http://www.sfmatch.org/fellowship/f_sports index.
htm
Trauma: http://www.sfmatch.org/fellowship/f_ota/
index.htm
SELECTION CRITERIA
Many factors will improve your chance of obtaining a

fellowship. The most important deciding factor is how you
performed during residency. This will be seen in the power
and depth of letters of recommendation and in your CV. How
you perform during residency predicts how you will perform
during fellowship.
Keys to Success in Residency

Five areas of development are the keys for being a good
resident and, subsequently, a desirable fellowship applicant.
These key areas are: (1) orthopedic knowledge, (2) clinical
judgment, (3) operative experience, (4) rapport with attending
physicians, residents, and support staff, and (5) research
(which is further described in the section).
When transitioning from medical school to residency,

you will have a great deal of medical knowledge but little
orthopedic knowledge. Throughout residency, orthopedic
knowledge is gained from direct experience, reading, and
conferences. It is important to gain a solid knowledge
foundation on which you will make clinical judgments.
While anatomy is still the most important knowledge to
have as a surgeon, learning how to make sound and relevant
decisions on the hospital floor, in the emergency room, and
in the clinic is an important skill that you should obtain as a
resident. Making excellent choices about patient care is good
for patients and builds trust with attending physicians, other
residents, and staff. As attending physicians trust residents
more, they often allow residents to operate more, thereby
improving residents’ operative experiences. Greater surgical
experience is also gained when you express interest and
work hard on each rotation, no matter what subspecialty you
eventually go into.
Building rapport with individuals within your residency
program is also important for establishing good relationships
outside of the program. As part of the fellowship process,
attending physicians that you work with may introduce you
to their colleagues at other institutions where you may want
to go for a fellowship. You can also get to know attending
physicians at other institutions by either doing “away”
electives during residency, if your program permits it, or
meeting attending physicians at conferences. Friendships
with other residents are important, as the best source of
knowledge about the fellowship application process comes
from individuals who have recently completed it. Finally,
treating staff well is an important skill in residency, fellowship,
and as an attending physician, as these individuals support
and assist you throughout your career. Sometimes during the
fellowship interview process, how you treat the coordinators
and secretaries can affect your application. If you treat
coordinators and secretaries well, they can be neutral or
favorable toward your application; however, if you treat staff
poorly during an interview, it will most likely be detrimental
to your application.
Importance of Research in Residency

Another important factor to your fellowship application is
research. In most residency programs, conducting a research
project is a mandatory factor for graduation. However,
instead of waiting until the last year of residency to conduct
a project, we advocate conducting research projects in
the subspecialty of your interest early on, so that accepted
abstracts, presentations, and publications can be included in
your fellowship application. Performing research gives you a
greater understanding of the research process and a deeper
appreciation of studies that published results in the literature.
It is ideal for you to conduct a complete research project that
includes the following elements: conceiving an idea, writing a
proposal, applying for grants, obtaining necessary approval for
conducting a study (e.g. Institutional Review Board approval),
administrating tests or performing chart reviews, collecting
and analyzing data, and writing a paper. If you are interested
in academics, performing these tasks during residency with
the guidance of others with greater experience in the field is
invaluable for undertaking future projects.
Conducting research projects also allows you to deter
mine if you are interested in pursuing a career in academics
or not. Many fellowship programs are specifically looking
for individuals interested in conducting research projects
to further their understanding in a certain field of research,
and it is frequently a topic of discussion during fellowship
interviews. Even if you are not interested in pursuing an
academic orthopedic position, conducting research pertinent
to your field of interest may be interesting for a short period of
time, and may provide areas for future research in fellowship.
Interviews
Once you are selected for an interview, it is important to
prepare for interviews at each institution. Being prepared
for an interview demonstrates to the program that you are
serious about their program and allows you to ask questions
to determine if the program is a right fit. The interview process
is beneficial for both the program and for you, as it is an
opportunity for both parties to evaluate each other. Generally,
there are four main components of interview preparation: (1)
preparing the logistics of attending the interview, (2) resear
ching each fellowship program, (3) preparing for questions,
and (4) preparing questions to ask during the fellowship
interview.
Once you accept an interview, you must secure time
off from residency (if you are currently in residency) and
make travel plans (transportation to and from the interview
and lodging). Oftentimes, fellowship programs have a social
event either the night before or the night of the interview, so
travel plans should be made accordingly. This is a key time to
interact with attending physicians and current fellows at the
institution, as it allows you to ask questions and learn about
the program in a relaxed environment. The dress code for
these events is often business casual, but it is never a mistake
to be too formal rather than too casual.
When arranging your travel schedule, be sure to build
in extra time to allow for delays. The worst thing to do is
show up late to a fellowship interview. While some events
are out of your control, you should make all efforts to ensure
a timely arrival at your interview. If a timely arrival is not
possible (e.g. plane delay), call the fellowship program
coordinator and notify him/her of your delay. Also, be sure to
appropriately budget which interviews to attend. Attending
interviews is a costly process, and you will almost always
pay for travel, lodging, and food expenses out of your own
pocket. We suggest that you retain receipts to qualify for tax
deduction. Some residency programs may provide some
financial coverage for the interview process, but this is not a
common practice.
Prior to arriving at the interview, you should research
each fellowship program. Almost all programs have a website
that offers information about the individual attending physi
cians in the program, as well as information for fellows, the
program’s research interest, and other pertinent information.
It is the key to know this information prior to interviews, as
it gives you possible topics of discussion, important areas
to focus on, and may raise relevant questions. At the end of
most interviews, the interviewer will ask you if you have any
questions. It is ideal to have an intelligent and well-formulated
question to ask at that time. Additionally, this is a chance
for you to ask questions about their criteria for fellowship
programs to determine if you would want to attend a specific
institution. Questions pertaining to the day-to-day experience
(clinically and socially) may be useful to ask during the
fellowship interview, as these questions are difficult to answer
from a web search.
Preparing for fellowship interviews differs from resi
dency interviews in that questions are more oriented toward
subspecialties and are often directed about your future.
A variety of questions are asked, but the most common
questions are “Why did you choose this specific subsp
ecialty?” and “What do you see yourself doing in 5 years from
now? 10 years from now?” With these questions, fellowship
programs can discern your motivation for doing a fellowship,
and determine whether or not you would fit well in the
program. For example, if you are interested in entering an
academic orthopedic practice and the fellowship program
does not conduct much research, there may be a mismatch
in expectations that should be addressed. Other questions to
prepare for include general orthopedic knowledge (especially
in your subspecialty), deeper questions about your research
and research interests, rapid fire questions to determine

how well you do under pressure, and questions about your
interests outside of work.
At the end of your interview day, be sure to thank all
the attending physicians who interviewed you, if possible,
as well as the support staff who helped to facilitate the inter
view process. Some programs discourage applicants from
sending thank you letters or e-mails, as the decision process
occurs right after the interview. If a thank you letter or
e-mail is permitted, it is a nice gesture to thank individuals
who interviewed you, as these people must cancel other
responsibilities to spend time with applicants. Additionally,
you may contact people in the program with questions after
the interview date. According to the match rules, the program
director cannot communicate anything about your ranking,
but can answer any questions about the fellowship. If you do
not receive communication from the program director, you
may also contact other individuals at the same program to ask
questions.
Rank List
The best way to determine how to rank programs is by
thoroughly researching fellowship programs. You should
search fellowship program websites, look at subspecialty
websites on fellowship programs, talk to current and past
fellows, and talk to others who have gone through the appli
cation process. The criteria covered in the above section
“Choosing where to apply” include some pertinent factors
for choosing fellowship programs. Making a list of what is
important to you in a fellowship program is the first step, and
making a pros and cons list for each program may be helpful in
determining a rank list. With the new match system, programs
are not allowed to discuss or disclose ranking information
with applicants. Any communication with programs is non-
binding, and may not hold true on Match Day. Thus, your
decision for ranking should be independent of what you hear
from any programs. A rank list should be submitted based
on where you want to go, not based on where you think a
program will rank you. The match is set up to favor you, as the
applicant’s first choice has greater weight than a program’s
first choice.
Rank lists on the SF Match are submitted by entering the
website and placing programs in the order of preference. It is
recommended that you rank every program you interviewed
for, as there is no financial repercussion for doing so. Once
the list is completed, this list is submitted; however, this
submission is not finalized until the last day rank lists are due.
Thus, this list may be modified as many times as desired until
the final day of the match.
Matching Process
Once rank lists are submitted for individuals and programs,
there is an approximate 1–4-week wait time until results are
announced. Program directors find out results the evening
before applicants find results, but are not allowed to discuss
these results with applicants until the following morning. You
can find your results by logging into respective websites (SF
Match or NRMP Fellowship Match) to determine if and where
you matched. An e-mail is not sent to applicants notifying
them of their matched program. The matching process is
binding, which means that you must attend the program you
matched at.
If you do not match, which may be common in more
popular subspecialties, you have the option to fill unmatched
spots. After the match is completed, most specialty websites
post available positions. If you are interested in these
positions, you should contact these programs directly and
initiate the proper application process.
CONCLUSION
The fellowship application match is a relatively straight-

forward process that gives you an opportunity to attend
fellowship programs to pursue additional training in the
subspecialty of your choice. You should consider many
factors when choosing a fellowship, and there are many
details to adhere to when going through the application and
interview process. With the advice and guidelines outlined in
this chapter, it is our hope that you obtain a fellowship that
provides you with the optimal clinical experience that you
hope to achieve.
13
Orthopedic Residency
in Canada
Marie-France Rancourt
INTRODUCTION
The Canadian health care system has received much attention
in recent years as it has been used for comparison when
discussing the changes in health care policy in the United
States. Canada offers universal health care for all its residents.
The 1984 Canada Health Act mandates comprehensiveness,
universality, portability, accessibility, and public adminis
tration of health care. With allocation of funds from the
federal government, each provincial government manages
and delivers its own health care system. Canadian orthopedic
surgery residents are essential members of the public health
care team.
The orthopedic surgery residency in Canada is well
structured and provides a quality education in orthopedics.
The relatively small number of programs across the country,
comprehensive research partnerships, academic affilia
tions, and rigorous regulations contribute to its favorable
international reputation. The residency application pro
cess is managed by the Canadian Resident Matching Service
(CaRMS). This service is an online service that standardizes
and centralizes residency applications for all orthopedic
residency programs in Canada. It is similar to the San Fran

cisco (SF) Match program in the United States in that it
processes and distributes the appro priate documents to
the desired programs. The application process is open to
both international medical graduates (IMGs) and Canadian
medical graduates (CMGs), often in two different streams.
Graduates of American medical schools are included in the
IMG stream. In Canada, there are a total of 14 English speaking
orthopedic residency programs, including six programs that
accept IMG applications in the first iteration. There are also
three French-speaking orthopedic residency programs with
none of them accepting IMG applications; thus applicants
must be French-speaking Canadians. All 17 programs are
affiliated with a university and are accredited every 5 years
by the Royal College of Physicians and Surgeons of Canada,
the profession’s national regulating body. Table 1 details list of
English-speaking orthopedic residency programs.
APPLICATION
The application process starts from the beginning of medical
school. Programs often identify quality medical students and
recruit them to their programs early on. Getting involved
with orthopedic research projects during medical school
will give you some exposure to orthopedics and help you
network with staff and residents. Summers are a great time
to work on research or participate in orthopedic electives.
We encourage you to complete as many orthopedic surgery
electives as possible prior to the CaRMS application deadline.
Programs are more likely to give interview invitations to
medical students who have shown interest in their program
and have demonstrated a strong work ethic. Some programs
even require an onsite elective in order to be considered for
an interview. Completing a 2–4-week elective is standard; it
allows both the program and the applicant time to familiarize
Table 1: English-speaking orthopedic residency programs
Universities and their location Annual quotas Gross annual income*
Universities City CMG IMG PGY-1 PGY-5
University of British Columbia Vancouver 5 $48,565 $68,642
University of Alberta Edmonton 3 $55,073 $76,624
University of Calgary Calgary 6 $55,073 $76,624
University of Saskatchewan Saskatoon 3 $54,715 $74,446
University of Manitoba Winnipeg 3 $54,956 $76,247
Western University London 5 1 $51,065 $71,995
McMaster University Hamilton 6 2 $51,065 $71,995
University of Toronto Toronto 10 2 $51,065 $71,995
Northern Ontario School of Medicine Thunder Bay 1 1 $51,065 $71,995
Queen’s University Kingston 3 $51,065 $71,995
University of Ottawa Ottawa 5 1 $51,065 $71,995
McGill University Montreal 3** $41,874 $59,129
Dalhousie University Halifax 3 $51,546 $73,035
Memorial University of Newfoundland St. John 2 $53,282 $75,495
(CMG: Canadian medical graduate; IMG: International medical graduate; PGY-1: Postgraduate year-1)
*In 2012
Orthopedic Residency in Canada
**Regular stream includes positions for both CMGs and IMGs
“chemistry” among residents and obtain added information

in many programs. Socializing will also allow you to see the
about the program. If possible, do some night calls to get

with residents as the residents have a strong selection input
an idea of the volume and variety of trauma cases handled at

themselves with each other. Take the opportunity to socialize
167
that center. Completing electives on both the East and West

coast shows a general interest for programs of each region.
Most of all enjoy yourself during your elective and take
advantage of these great learning opportunities.
Once it is time to start the official application process,
ensure that you meet all criteria to be eligible for the first
iteration of the match. For the CMG stream, the applicant
must obtain a Canadian medical degree by July 1 of the
match year and be a Canadian citizen. For the IMG applicant,
the applicant must obtain a medical degree by July 1 of the
match year from an international medical school listed with
the international medical education directory (IMED). They
must speak English and have had no previous postgraduate
residency training in Canada or the United States. Passing
score reports from the Test of English as a Foreign Language
(TOEFL), International English Language Testing System
(IELTS) or Test of Spoken English (TSE) are accepted as proof
of English proficiency if the applicant’s home country does
not speak English as a first language. Most provinces do not
accept the USMLE, thus IMGs must have written and passed
the Medical Council of Canada Evaluating Examination
(MCCEE) Parts 1 and 2. Please note that all provinces, except
Quebec and Alberta, have “return of service” obligations
for IMGs who successfully match to an orthopedic surgery
residency position. Terms vary slightly by province but often
mandate that once graduated from residency, the physician
must stay and work in that same province for a predetermined
amount of time. The province will often allocate the graduate’s
services to areas of “need” or “under service” as determined
by the province. If the physician fails to complete their return
of service contract, they will be required to pay a monthly
penalty plus interest.
Once you have confirmed your eligibility and have
decided to apply to orthopedic surgery residency in
Canada, familiarize yourself with the application process at
Orthopedic Residency in Canada 169
www.carms.ca. You will select which schools and which
specialties you wish to apply to. Respect the deadlines stated
for that match year, as they are not flexible. The timetable
varies from year to year but generally follows this format:
Year prior to start of residency:
•• August–September: CaRMS online application opens
•• October–November: Submission of supporting documents
•• November: Application deadline
•• December: Interview invitations
Year of start of residency:
•• January–February: Interviews
•• February: Applicant rank order list deadline
•• March (12:00 ET): Match Day
Be sure to gather all the appropriate documents needed for
the application:
•• Medical school transcript
•• Medical student performance record or dean’s letter
(MSPR)
•• Letters of reference
•• Proof of Canadian citizenship status
•• Personal letter
•• Photograph
•• Extra documents (as needed)
Use a mail delivery system with a tracking system when
mailing your documents to the CaRMS. You should also keep
a copy of documents sent for your own personal records. The
medical school transcript and MSPR should be sent by your
medical school directly to the CaRMS, but you must ensure
reception by logging in to your account. The proof of Canadian
citizenship can be a passport or birth certificate among other
documents. There is no maximum number of reference letters
you may send to the CaRMS. Ask those staff you have worked
with for a reasonable amount of time (1 week or more) and
those who you believe could write a favorable reference letter
on your behalf. The letters must be from a staff member, not a

resident, and should preferably be from orthopedic surgeons.
The staff will write a blinded reference letter and send it to the
CaRMS office. In order to make this process easier for them
and to ensure their letter reaches the CaRMS office on time,
give your referee a detailed letter with the deadlines and goals
of the reference letter as well as a prepaid and preaddressed
envelope with a tracking number. Once all your reference
letters have been received by the CaRMS office, you may select
which letters to send to which schools with most schools
asking for three reference letters. For the personal statement
letters, you may write individual ones to accompany each
program application. This individualized approach makes the
personal letters more specific and relevant.
The IMG applicants will provide the same documen
tation as stated above for the CMG applicants as well as
the extra examination reports. The extra examination score
reports include English proficiency tests such as the TOEFL
and the TSE, which need to have been passed within the last
2 years. Other examinations score reports such as the MCCEE
Parts 1 and 2 must also be submitted. Please note that all
documentation sent to the CaRMS must be accompanied by
an official translation if the document is written in a language
other than English or French.
Statistics for the Year 2012

CMG Applicants
•• 117 applicants for 76 CMG orthopedic surgery positions
(including French residency programs)
•• On average, applicants applied to 10–14 programs in one
or two disciplines
IMG Applicants
•• 145 applicants for seven IMG orthopedic surgery posi
tions
•• On average, applicants applied to 13–20 programs in two
to three disciplines
INTERVIEWS
The interviews in Canada are well coordinated between all

the orthopedic programs. By having a predetermined national
interview schedule, everyone interviews the same day for
a particular program and no interviews overlap or conflict
with one another. This allows applicants to attend all the
interviews they wish. The interviews are referred to as the
“Ortho Tour” as the interviews are scheduled coast to coast in
geographical order. The tour either starts in the West [usually
University of British Columbia (UBC)] or in the East (usually
memorial) and interviews are held every day to every 2 days in
a period of just over 2 weeks. This system is more economically
advantageous for the applicants as the flights are shorter
distances and do not crisscross the country. This tour format
also allows for great cama raderie between applicants as
they spend 2 weeks together getting to know one another by
socializing and sharing hotels and taxis.
Most programs have a social function the night prior
to interviews. This social night can include anything from a
formal dinner to a casual cocktail in a local pub. We recom
mend that you research the venue prior to attending in order
to determine the appropriate attire for the evening. These
evenings are a great time to learn about the program as the
program director, staff, and residents are often present.
This informal setting gives you the perfect opportunity to
ask questions and see the camaraderie among the program
residents and staff. A good turnout of residents and staff
shows that they are invested in their program.
The interview format for each program varies but often

consists of two or more interview panels made up of two
or more staff or senior residents. Breakfast and/or lunch is
provided and is often accompanied by a short presentation
about the program. The expected attire is of neutral colors;
business suit with tie for men and business suit or skirt to the
knees for women. During the interview, be sure to maintain
eye contact and sit up straight with your hands on your lap.
The panels will often ask you if you have any questions at the
end of the interview so you should have one or two questions
prepared. The interview questions cover many different
subjects. They will have your curriculum vitae (CV) in hand
and will use it as a reference point for questions; thus know it
very well. Questions often fit in one of the following categories:
•• Ethics
•• Personal (as per CV)
•• Previous research
•• Typical interview questions (i.e. describe a time when...)
•• Current topics.
Prepare your responses to often-asked questions prior to
the interview. Most important, “be yourself”!
DECIDING ON A RESIDENCY
After the interview process, the matching process begins.
This decision is one of the biggest decisions of your career
and should not be taken lightly. Since residencies in Canada
are so well regulated, any residency will provide you with
excellent orthopedic training. What you must decide is which
residency will suit you better: your personality, your learning
style, and your goals. Some aspects of residency may carry
more weight than others and some may be requisites in your
decision making. Below is a list of some criteria to consider
when choosing a residency:
•• People
−− Staff
■■ Willingness to teach
■■ Collegiality among staff
■■ Staff to resident ratio
■■ Number of fellows
■■ Program director
−− Residents
■■ Social outings
■■ Camaraderie
•• Money
−− Salary
−− Call stipends
−− Meal stipends
−− Parking costs
−− Living costs
−− Health care coverage
−− Grants for courses
•• Program
−− Elective time
−− Off service rotations
−− Availability of all orthopedic subspecialties
−− Option and support for postgraduate education
−− Structured and protected study and education time:
journal clubs, academic half-days, etc.
−− Examination preparation (time off, mock orals)
•• Research
−− Protected time
−− Requirements
−− Financial support
•• Call
−− Frequency
−− Weekend calls
−− In house vs. home call
−− Volume of cases on call

−− Post call days
•• City
−− Accommodation availability
−− Activities: concerts, plays, sport venues
−− Proximity to family
•• Reputation
−− Past Royal College of Physicians and Surgeons of
Canada reviews
−− Fellowships obtained by graduates
•• Organizational support
−− Program coordinator
−− Cast technicians
−− Day care
•• Facilities
−− Number of hospital sites
−− Surgical skills labs, libraries, call rooms
Based on your criteria, you must find the residency that is
right for you. Rank honestly based on where you would like to
spend 5 years of your life.
RANKING AND MATCHING
Both the applicant and the program individually submit

their rank order list. We advise you to rank the programs in
your true preference order. It is important to only rank the
programs that you are willing to attend since once you are
matched to a certain program, there is no option to withdraw
or switch. Even if you attended a program’s interview, you do
not need to include that program in your rank list. You must
ask yourself: “Would I rather not match at all than match to
that program?” As orthopedics is a competitive specialty, we
also encourage you to list as many acceptable programs as
possible to increase your chances of matching. The matching
algorithm favors the applicant as it first attempts to match the
applicants to their preferred program.
Couples may submit their rank order list together
to ensure that they match to the same institution. Some
flexibility in specialty choice is needed from at least one
partner to increase the chances of the other partner to match
to orthopedic surgery. More the combinations entered,
whether by specialty or city, the better are chances of the
couple matching.
Programs will base their matching selection criteria on
past research, orthopedic electives, grades, and letters of
recommendation. Most important, they will match based on
the personality of the applicant and how well that applicant
would suit their program. They primarily ask themselves:
“Can I work with this person every day for 5 years?” They can
teach the applicant orthopedics but they cannot teach them
teamwork, ethics and hard work.
You may return to the website multiple times to change
or view your rank order list, but be sure to save your changes
before you exit the site. Once you have submitted your rank
order list, no changes are permitted. Do not wait until the
last minute to submit your rank order list as the website often
sees increased traffic during the last few hours. A saved list
is not a submitted list, and there are no exceptions made for
applicants who did not submit their rank order list.
Matching notices are posted on the CaRMS website at
noon Eastern Time on Match Day. At that time you may login
to your account and see which orthopedic surgery program
you have matched to. Once again, there are no changes
allowed. You may now plan your new life as an orthopedic
surgery resident!
SECOND ITERATION
The applicants who do not match in the first iteration may
match in the second iteration. The residency positions that
were not filled during the first iteration are made public 1
hour after the match of the first iteration. In 2011, three CMG
positions went unmatched in orthopedic surgery. The second

iteration is also a time when some IMGs can apply for the first
time, thus adding a new category of applicants to the pool.
The applicants who did not match may now look at the
available residency vacancies in all specialties and apply to
those they wish to apply for individually. The second iteration
timeline is much shorter, as applicants now have 1 week to
apply to programs and must submit their rank order list
within 2 weeks. The Match Day is usually 4 weeks after the
second iteration opens.
RESIDENCY LIFE IN CANADA
Health care in Canada is delivered by the provinces; thus each

province will have different budgets and regulations. Within a
province, all residents will have equal pay and contracts. The
residents are represented by provincial unions that ensure
benefits and a healthy work environment. All provinces offer
a minimum of 4 weeks of paid vacation plus/minus paid
educational leave and parental leave. In some provinces
monetary stipends are provided for meal allowances and call
shifts (in house or home based). Benefits vary by province but
often include insurance such as medical, dental, extended
health, life and disability insurance. Each resident pays a
monthly fee to be represented by the Canadian Medical
Protective Association (CMPA) which provides legal advice
if needed. The majority of fees paid for representation by the
CMPA are often reimbursed by the province.
In 1996, the Royal College of Physicians and Surgeons
of Canada and orthopedic residency programs identified
the seven roles of a specialist physician to ensure optimal
outcomes: medical expert (central role), communicator,
collaborator, manager, health advocate, scholar and profe
ssional. In addition to developing surgical skills, each program
concentrates on developing these key roles.
A typical day in most programs includes making rounds
on your team’s patients prior to 7:00 am in order to attend 7:00
am teaching or handover rounds. Operating rooms and clinics
usually start at 8:00 am and finish between 4:00 pm and 6:00
pm depending on the site. Night call varies from site to site
but is usually from 5:00 pm to 8:00 am and may include
covering one or multiple campuses. Night call can also be
solo or in a team of junior and senior resident. The frequency
of call shifts is 1 per 4 days if call is in-house call (must stay
at the hospital during the entirety of the call shift) or 1 per
3 days if call is home call (may go home if nothing requires
your attention at the hospital). The amount of operating done
during night call varies but daytime trauma rooms have for
the most part eliminated or decreased nonurgent procedures
being done after midnight. Call stipends and meal stipends
while on call are included in some provinces.
In order to graduate from residency, there are two
tests to pass. Both of these tests have fees associated with
them that are not covered by the program. The first is the
surgical foundations examination that may be taken after
a minimum of 2 years of training but must be taken prior
to the second examination. Most residents elect to take the
surgical foundations examination at the end of their second
year of residency, after finishing their core surgical rotations.
In the spring of your final year of residency you must pass
the second test, “The Quiz”: the Royal College of Physicians
and Surgeons of Canada Orthopedic Surgery Examination.
It includes a written component of multiple choices and
short answer questions as well as an oral examination
comp onent. In 2011, 92 residents took the examination
with 80 residents successfully passing the examination for a
94% CMG pass rate. Passing this test is necessary in order
to obtain your designation of FRCSC (Fellow of the Royal
College of Surgeons of Canada). Most programs in Canada
prepare their residents for this exam by decreasing clinical
duties in order to allow more study time or to organize

mock oral examination. Once you have passed this exam
examination and completed 5 years of residency training,
you may practice orthopedic surgery in Canada. Congrat
ulations, you are now an orthopedic surgeon!
FURTHER READING
All statistics obtained from www.carms.ca

Military Candidates
and the Secrets to a
Successful Match in
14
Orthopedic Surgery
Residency and
Fellowship
Major Jonathan F Dickens, Captain John P Cody,
Major Melvin Helgeson, Colonel Scott B Shawen
HISTORY
The history of military medicine is rife with examples of

heroism, leadership, and surgical development. The earliest
documented military medical unit was founded during
the Revolutionary War as the United States Army Hospital
Department on July 10, 1775.1 Throughout our nation’s
history, a significant portion of medical care distributed to
soldiers wounded in combat throughout all major conflicts
was orthopedic in nature; however, it was the development
of the Department of Military Orthopedic Surgery during
World War I that marked the formal beginning of military
orthopedics.1 Since that time, military orthopedics has
grown to include departments in the Army, Navy, and Air
Force and has capabilities at almost every military hospital
in the continental United States and abroad. As our military
continues to advance in their development of life-saving
protective gear, resuscitation measures, and medevac opera
tions, survival rates have increased, which has lead with each
subsequent conflict to a larger number of wounded soldiers
requiring orthopedic care.2,3
The military orthopedic trauma experience is unique

and fosters an environment for significant surgical and
technological advances that has benefitted civilian and
military orthopedic surgeons alike for generations. A number
of orthopedic techniques for stabilization of fractures and
management of traum atized soft tissue can be traced to
wartime military orthopedics. Former military orthopedic
surgeons were instrumental in the recognition of orthopedic
surgery as a surgical subspecialty in the civilian community
as well. During the late 19th and early 20th centuries,
several national groups (including the American Orthopedic
Association and the American Association of Orthopedic
Surgeons) were founded. Not surprisingly, a majority of the
early leaders were individuals who had served as military
orthopedic surgeons during times of conflict.1
The history of military orthopedics, the presence of
a young, active patient population, and the world-class
instruction from staff with a variety of backgrounds should
make military orthopedic residency a consideration for those
orthopedic-bound undergraduates or medical students who
desire to serve their country.
MILITARY PAY AND INCENTIVES
Aside from the significant history and the opportunity to serve

your country, there are some distinct benefits to completing
an orthopedic surgery residency in the military. Most civilian
residency programs pay between $45,000 and $58,000 per
year (before taxes). The differences generally are due to local
cost of living.4 In comparison, military residents are paid
based on their active duty rank, which includes basic pay
and basic allowance for housing (BAH). Basic pay increases
incrementally depending on years of service and rank. BAH is
tax-free income, which increases based on rank, local cost of
living, and whether or not the service member has a spouse
Military Candidates and the Secrets to a Successful Match 181
and children. Additionally, the government provides variable
special pay (VSP) for medical officers in all services, which
presently starts at $1,200 per year for interns and increases
to $5,000 per year for remaining years of residency. In direct
comparison of the 2010 salaries for civilian orthopedic
surgery residents, military residents can expect a salary of
$75,000 to $90,000 per year, depending on the BAH rates at
their assigned medical center.5
While the resident pay is significantly higher in the
military compared to the civilian community, the pay increase
upon residency graduation is markedly decreased on the
surface, but there are incentives to practicing in the military
from a monetary perspective after residency as well. Again,
BAH is tax-free income, and in some instances can be up to
30% or more of your yearly salary. In addition to the VSP, the
military offers annual Specialty Pay of approximately $36,000
that is started upon completion of residency and continues
for the remainder of service. As a practicing physician in
the military health system, you are not required to purchase
expensive malpractice insurance. Military physicians can be
named in lawsuits and reported to provider databases if any
monetary settlement is awarded, but they are not directly
financially responsible for any settlement). Finally, you
and your entire family (spouse/children) receive full health
benefits without any additional cost. Therefore, while the
salary in the military as a board-certified orthopedic surgeon
is lower compared to your civilian counterparts, you benefit
from numerous tax incentives for military members, take
home a higher percentage of their pay, and avoid additional
expenses such as malpractice insurance or family healthcare.
MILITARY SERVICE
Another unique aspect of military orthopedic surgery resi

dency is the opportunity to serve your country both at home,
through the care of those training for their wartime mission,

and abroad, in the care of military men and women directly
in harm’s way. On the whole, the patient population is young,
healthy, active, compliant, and dedicated to returning to duty.
There are several ways in which you can join the armed
forces for residency. Most commonly, medical school
bound undergraduates apply for the Health Professions
Scholarship Program (HPSP) to a civilian medical school or
to the Uniformed Services University of the Health Sciences
(USUHS), which is a military specific medical school. HPSP
covers tuition, will reimburse for book and medical supply
purchases, and provides a monthly stipend for living expenses;
in turn, students incur a 4-year duty commitment, which
must be paid back following residency. USUHS students
receive more pay based on their time in service and housing
allowance, and as a result incur a 7-year duty commitment.
Payback of indebted time essentially begins with com
pletion of residency. The wording in the regulations state
that you incur additional obligation with residency in the
same number of years as the residency, but that the medical
school obligation and residency obligation may be paid
back concurrently. In a basic sense, this means that if you
match in a 5-year military orthopedic surgery residency,
then you will end up paying back 5 years after residency.
Essentially, military physicians end up owing the military
4 years for medical school or the time equal to the length of
their residency, whichever is longer. For orthopedic surgery
residents, this generally means 5 years of obligation following
a 5-year residency, for a total of 10 years of service in the
military at the end of their obligation.
Two Army-specific fellowships are available (hand
and microvascular surgery, located at Walter Reed National
Military Medical Center and the John Feagin Sports Medicine
Fellowship, located at Keller Army Community Hospital in
West Point, New York), but most residency graduates applying
for fellowship apply to civilian fellowship training programs.
You may be receive your fellowship training as a sponsored
or nonsponsored trainee. Nonsponsored training generally
occurs in the Navy and Air Force, and allows the trainee
to attend a civilian fellowship program without incurring
additional military obligation, but it is done without the
benefits of being on active duty status during the training
period. As a nonsponsored trainee you will not receive active
pay and benefits during the fellowship training. Sponsored
fellowship training is more common in all branches of
services. The sponsored trainee is approved and selected for
civilian fellowship and receives active duty military benefits
and pay during the training period. Attending a sponsored
fellowship does incur an additional service obligation, which
is generally two years for each year of fellowship.
During periods of medical training (internship, residency,
and fellowship), service members maintain a “nondeploy
able” status, to ensure that they can be trained without
interruption. In the past, all services would require a period
of “general medical officer (GMO) time” following internship;
however, this is becoming less common. The Army and Air
Force currently do not require GMO time for those accepted
into a residency, and the Navy requires approximately 30% of
their physicians to serve in a GMO status following completion
of their intern year. During GMO tours, service members are
frequently deployed.
Deployments for board-certified orthopedic surgeons
are generally 4 to 6 months in duration (compared to the
12- to 15-month deployments for most active duty units),
and while this time is characterized by long days, difficult
surgical and mental situations, and being apart from your
family, most surgeons view their deployment experience as
invaluable, both from a professional and personal perspective.
While there are opportunities in civilian medicine to volunteer
your time abroad for an underserved population, the acuity
of care and the specific patient population during combat is

unique to the military service.
MILITARY ORTHOPEDIC
RESIDENCY PROGRAMS
Orthopedic residency in the US Military is offered in all

branches of service (Army, Air Force, and Navy). There are
six Army orthopedic programs, which train 19 Army residents
each year, three Navy orthopedic programs that train 12
residents annually, and one Air Force orthopedic residency
that trains 4 residents per year (Table 1). Based on the needs
of the Army Navy and Air Force additional residents can be
offered to sponsored residency to attend civilian orthopedic
residency training programs. The individual military ortho
pedic residency programs are discussed in detail below.
Walter Reed National Military Medical Center

The National Capital Consortium (NCC) Orthopedic Resi
dency is located at Walter Reed National Military Medical
Center in Bethesda, Maryland. The campus is co-located with
the Uniformed Services University of the Health Sciences
(USUHS) and is adjacent to the National Institutes of Health
Table 1: Military orthopedic residency programs

Program Army Navy Air Force
Walter Reed/NCC 3 3 X
San Antonio USHEC 4 X 4
William Beaumont 4 X X
Eisenhower 2 X X
Tripler 3 X X
Madigan 3 X X
NMC San Diego X 5 X
NMC Portsmouth X 4 X
and National Library of Medicine. The recently completed
renovation of the hospital campus and orthopedic clinic
provides residents with the best facilities in the military, a
state of the art surgical simulation center, over 20 new main
operating rooms, as well as new clinic and office space. Walter
Reed is an integrated orthopedic residency with three Army
and three Navy orthopedic residents in each class. Walter
Reed is the only program in the military to offer a one-year
research fellowship to all orthopedic residents following
the PGY-3 year. During this year, residents pursue research
opportunities, which have included clinical research at Walter
Reed and the United States Naval Academy as well as basic
science research at the National Institutes of Health, Walter
Reed Spine Lab, NMRC, and the Walter Reed Army Institute
of Research. Residents complete rotations in all subspe
cialties with fellowship trained orthopedic surgeons at Walter
Reed and complete outside rotations and The University
of Maryland SHOCK Trauma Center, United States Naval
Academy Department of Sports Medicine, and Children’s
Hospital of Pennsylvania.
San Antonio Uniformed Services

Health Education Consortium
San Antonio Uniformed Services Health Education Consor
tium (SAUSHEC) is an integrated orthopedic residency
program that trains four Air Force residents and four Army
residents annually. The Fort Sam Houston installation,
combined with Lackland and Randolph Air Force Base,
serves as the home to the Army Medical Department, houses
the military Medical Education and Training Campus and
the Institute of Surgical Research. These intrinsic resources
provide numerous opportunities for education and research
to orthopedic residents. The program offers both a 5- and
6-year training program with the additional year available for
research to selected residents. In addition to the subspecialty

orthopedic training at Brooke Army Medical Center, residents
also enjoy rotations at The University of Texas Health Sciences
Center at San Antonio and Denver Children’s Hospital. The
resident academic education is primarily conducted on
Monday. Army and Air Force residents attend didactic lectures
with residents from the University of Texas Health Sciences
Center in the morning. Additional lectures, postoperative and
anatomy conferences are conducted at the BAMC.
William Beaumont Army Medical Center

The orthopedic surgery residency program at William Beau
mont Army Medical Center/Texas Tech University Health
Sciences Center (WBAMC/TTUHSC) in El Paso, Texas, is the
only combined military and civilian orthopedic residency
program in the country. Following graduation, residents
receive diplomas from both WBAMC and TTUHSC. William
Beaumont Army Medical Center is a 250-bed Level III
trauma center nestled in the mountains centrally in El Paso,
which serves an active-duty population of approximately
30,000 soldiers, their families, and other beneficiaries. The
University Medical Center of El Paso is the only Level I trauma
center in the surrounding 250-mile radius, serving 1.1 million
people of West Texas and Southern New Mexico. Residents
work closely with staff and basic scientists at both WBAMC/
TTUHSC to fulfill their research requirements. Orthopedic
Surgery Residents complete rotations in subspecialties
with fellowship trained orthopedic surgeons at WBAMC/
TTUHSC and complete outside rotations at Rush University
in Chicago and the University of Utah. Success in research
and academics coupled with the excellent surgical training
opportunities available result in an outstanding orthopedic
surgery residency program.
Eisenhower Army Medical Center (Cody)

The Eisenhower Orthopedic Surgery Residency Training
Program located in Augusta, Georgia, is a 5-year program
that trains two residents in each class. Residents gain
extensive exposure and practical experience in all phases of
reconstructive surgery, spine surgery, sports medicine, hand
surgery, pediatric orthopedics, complex trauma, prosthetics,
orthotics, and complete inpatient and outpatient care.
Residents rotate for six months at the nationally renowned
Scottish Rite Children’s Medical Center in Atlanta, Georgia,
where all aspects of pediatric orthopedics are covered.
Orthopedic trauma training is concentrated through rotations
at the University of South Carolina and University Hospital of
Augusta, Georgia. Research is encouraged and residents have
the opportunity to do 3 to 4 months of dedicated basic science
and clinical research.
Tripler Army Medical Center

Tripler Army Medical Center, located in Honolulu, Hawaii, is
the primary military treatment facility in the Pacific theater,
providing care for over 250,000 active, dependent, and retired
service members throughout Hawaii and as a tertiary referral
center complex orthopedic care from throughout the Pacific
theater. Tripler provides a fully accredited 5-year orthopedic
residency program that trains three Army residents annually,
and offers residents the opportunity to combine a rigorous
academic experience while living in one of the most desirable
places on earth. Residents complete a categorical orthopedic
surgical internship as a PGY-1, which includes 6 months of
orthopedic rotations, 3 months of surgical and subsurgical
training, and 3 months of additional training designed to
provide a solid foundation of surgical skills training and
decision making. As a PGY-2 resident, you will rotate on
trauma, sports medicine, pediatric orthopedics, and hand

surgery at Tripler, as well as attend one of the national
AO conferences in orthopedic trauma basics. As a PGY-3
resident, you will complete subspecialty training in spine,
foot and ankle, and orthopedic trauma at Queens Hospital
in Honolulu, and attend the acclaimed Orthotics and
Prosthetics course in Dallas, Texas. PGY-4 residents perform
senior rotations in orthopedic traumatology at the University
of Maryland Shock Trauma Center in Baltimore, as well as
complex pediatric orthopedics at Texas Scottish Rite/Dallas
Children’s in Dallas, and as a senior level experience in sports
medicine at Tripler. In addition, PGY-4 residents have a month
of dedicated research time protected to complete scholarly
activity begun earlier in their careers, and they attend the
Enneking Orthopedic Oncology Course at the University of
Florida. The chief residency year (PGY-5) is spent at Tripler
and includes rotations in adult reconstruction, hand surgery,
and sports medicine, and is designed as a bridge to transition
residents into becoming young orthopedic leaders. Chief
residents attend the annual Society of Military Orthopedic
Surgeons meeting, as well as the annual AAOS meeting. Since
1960 Tripler has obtained a 100% ABOS board certification
with a 100% first time pass rate for Part I and Part II of the
ABOS in the past 10 years. Tripler graduates have gone on to
prominence as orthopedic chairmen, fellowship directors,
and subspecialty leaders.
Madigan Army Medical Center

The Madigan Orthopedic Surgery Residency is located at
Fort Lewis in Tacoma, Washington. The program accepts
three Army residents each year into a categorical orthopedic
residency. The intern year includes three orthopedic rotations,
five surgical and surgical subspecialty rotations, and four
nonsurgical rotations. During the PGY-2 year residents rotate
on general orthopedic teams at Madigan, attend the AO
basic fracture course, Clinical Investigation Basic Research
Course, and the Dallas Orthotics and Prosthetics Course.
The PGY-3 through PGY-5 years are focused on orthopedic
subspecialty training; residents rotate at Harborview Medical
Center in Seattle, Children’s Hospital and Medical Center in
Seattle, Shriner’s Hospital in Spokane, and a local community
hospital for adult reconstruction. In-house orthopedic call
is covered by residents in their PGY-2 and PGY-3 years, with
senior residents serving as backup. The academic curriculum
includes weekly morning call and postoperative conferences,
with Wednesdays devoted to didactic lectures and grand
rounds given by teaching faculty and residents. In the first
quarter of the academic year, anatomy dissections are
performed by the junior residents and corresponding lectures
are given by a world renowned University of Washington
Professor of Anatomy.
Naval Medical Center Portsmouth

Serving the largest fleet concentration in the Depart
ment of Defense, the Orthopedic Surgery Department at
Naval Medical Center Portsmouth (NMCP) in Portsmouth,
Virginia, is the busiest orthopedic service in the Navy. The
staff consists of fellowship-trained specialists in sports
medicine, pediatrics, hand, spine, trauma, foot and ankle,
joint reconstruction, and oncology, covering the entire
spectrum of musculoskeletal medicine. NMCP trains four
Navy orthopedic residents per year and offers the Navy’s
only Orthopedic Physicians Assistant Training program.
In addition to rotations at NMCP, “away” rotations in trauma
at Tampa General, joint reconstruction at New England
Baptist Hospital, and pediatrics at Children’s Hospital of the
King’s Daughters are offered. With this regimen, approxi
mately 6500 outpatients and 300 surgeries are performed
monthly. This volume generates approximately 1400 surgical

cases, as either the primary or first assist surgeon, for the
graduating chief residents.
Naval Medical Center San Diego

San Diego is home to the largest Naval Operations Base on
the west coast as well as the largest Marine Corps Air Station,
Marine Corps Base, and Marine Corps Recruit Depot on the
west coast. Naval Medical Center San Diego (NMCSD) serves
as a tertiary referral hospital for active duty and retired Navy
and Marine Corps personnel and their dependents stationed
in the Western United States as well as those stationed across
the Pacific Ocean to include Japan. The Medical Center
features a 277-bed hospital with 18 operating rooms as well
as a recently renovated state-of-the-art Orthopedic Surgery
Clinic and surgical simulation lab. Two outpatient surgery
centers provide additional space for elective surgical
procedures. The orthopedic surgery residency program at
NMCSD is a fully accredited 5-year residency, which trains
five residents annually. Every orthopedic subspecialty is
represented at NMCSD, but residents obtain additional
training in orthopedic traumatology at the University of
California San Diego and Denver General Hospital. Further
geriatric orthopedic and community trauma experience is
obtained via rotations at Kaiser Permanente and further
pediatric orthopedic surgery training is obtained via rotations
at Rady Children’s Hospital—San Diego. Residents from the
University of California San Diego rotate through NMCSD
for additional training in sports medicine surgery. The
NMCSD Orthopedics Residency places a strong emphasis
on academics, and residents participate in a combined
orthopedic academic curriculum with weekly academic
conferences in conjunction with the University of California
at San Diego.
APPLICATION AND
SELECTION PROCESS
The military orthopedic match requires a separate appli
cation from the civilian orthopedic match process. Applicants
to military orthopedic residency typically enter after having
previously accepted scholarship funding to attend civilian
undergraduate education (Reserve Officers Training Corps,
ROTC) or medical education (Health Services Professional
Scholarship Program, HPSP). Additionally, others attend
the military service academies for undergraduate education
or the Uniformed Services University of the Health Sciences
(USUHS) for medical school. All applications with a military
service obligation must apply to the Tri-Service Joint Services
Graduate Medical Education Selection Board (JSGMESB) for
first-year graduate medical education (FYGME) through the
central application for each service (Table 2). Infrequently,
applicants seek to enter the military and apply to military
orthopedic residency programs after having completed their
medical education. This untraditional career path is possible
but requires significantly more planning.
Just as civilian orthopedic residency slots remain
among the most competitive and coveted positions, so too
does military orthopedics. On average, there are two to
three applicants for each orthopedic residency slot in the
Army, Navy, and Air Force each year. The smaller number of
orthopedic positions in the military compared to the civilian
match makes the match process more variable, and from
year to year different services may receive more orthopedic
Table 2: Graduate medical education application Information

Website
Army www.mods.army.mil/medicaleducation
Navy/Marines http://www.med.navy.mil/sites/navmedmpte/gme
Air Force www.airforcemedicine.afms.mil
residency applications. Although the number of orthopedic

applicants to each service (Army, Navy and Air Force) varies,
acceptance is competitive and orthopedics is consistently
among the top three most competitive military residency
matches. From 2010 to 2012 the average USMLE Step 1 score
of accepted applicants was approximately 240. Accepted
applicants received honors grades in approximately half of
their general science classes and clinical rotations. Many
of the accepted applicants were elected into Alpha Omega
Alpha, and almost all received honors grades in general
surgery and orthopedics rotations.
While the military and civilian match processes require
different applications, the content of the applications is
remarkably similar. The military applicant must apply
using the ERAS and the military match. Both applications
require that the applicant write a personal statement, prepare
a curriculum vitae, request letters of recommendation,
obtain a Dean’s letter, send transcripts, and submit
USMLE or COMLEX scores. Importantly, the deadline for
JSGMESB application, except the Dean’s letter, is mid-October
(Table 3). Consequently, the ERAS application, personal state
ment, letters of recommendation, away rotations, interviews,
USMLE Step II CK, and the rank order list for military pro
grams must be submitted by the mid-October deadline.
Table 3: Important dates for the military match

July 1 Online application opens
July to November Away rotations
September 30 Deadline to submit web application
Mid-October Deadline for applicant preference list
October 30 Complete interviews
Last week of November Selection board convenes
Second week of December Selection board results released
First week of January Deadline for training acceptance
The early deadline for the JSGMESB requires that the
military applicant must complete several requirements
before their civilian counterparts. USMLE Step II CK generally
requires 4 to 6 weeks to report scores; thus military applicants
should take the exam before September 15 to ensure scores
are reported before the deadline. Additionally, many schools
do not prepare Dean’s letters prior the October 15 application
deadlines. While the letter does not need to be submitted prior
to October 15, it is should be completed before the JSGMESB
meeting.
Away rotations are among the most critical components
of the application process and require careful planning and
preparation. Medical students on an HPSP scholarship
are required to do a minimum of one 30-day active duty
subinternship rotation and during this period are paid the
salary of an active duty officer. Many applicants will do
three away rotations, and those with weaker grades and
board scores should strongly consider maximizing the away
rotation opportunity. Since the rank list is due by October 15,
you should expect that many fourth year medical students
rotate from July to November. There are limited positions
for orthopedic subinternships each month and students
that wish to rotate, especially in the months from August to
October, should contact the medical student coordinator at
the program as well as the GME office at the hospital at least
6 months in advance to coordinate the rotation. Most rota
tions are 4 weeks; however, some students choose to rotate for
as few as 2 weeks.
The away rotation is an audition for both the applicant
and program, and it is the most effective way for the program
to get to know the applicant and vice versa. As such, it is rare
that an applicant is accepted to a program without rotating at
that program. Military orthopedics is a team-based specialty
that emphasizes a “work hard, play hard” mentality. Ideal
applicants will demonstrate during their rotation the qualities
that will make them a successful resident. The rotating

medical student should aim to do the job of the intern
without direction. Medical students who are motivated, able
to function independently, and take on the responsibilities of
an intern will stand out among other students. The medical
student should demonstrate continued interest in the field
of orthopedics by preparing for cases, reading orthopedic
journals and texts, and mastering the applied surgical
anatomy. Those students who demonstrate those traits while
being personable, confident, and easy to get along with will be
successful in the orthopedic match.
Interviews are an important component to the appli
cation process and these can be done in person during the
away rotation or at a scheduled date as well as over the phone.
The majority of students will interview with the program
director and faculty during the away rotation. Students who
do not rotate at a program, and especially weaker applicants,
should strongly consider coordinating telephone interviews
or in-person interviews with the programs they do not rotate
to. The interview process varies among different programs;
however, all program directors are required to complete GME
interview sheet that is standard for the interview. Through
interview applicants are graded by their personal appearance
and military bearing, communicative skills, professional
demeanor and maturity, demonstration to and responsibility
for continued learning and patient care, potential success
for graduate medical education, and potential success as a
military medical officer.
The last week of November the JSGMEB, including
all residency program directors for each branch of service,
meets to create an order of merit list (OML) of all applicants
and select incoming trainees. Applicants are scored based
on the preclinical medical school performance, clinical
medical school performance, and potential for success. The
committee members take into account the entire application,
but the JSBMEB point system provides objective criteria
to create an applicant OML. Knowledge of the application
scoring components may be useful when putting together
an application. Medical students can earn a maximum of
10 points. Up to 2 points are awarded for the first 2 years of
medical school and are based of the USMLE Step 1 score and
preclinical grades. Three points are available for academic
performance during the third year of medical school and the
USMLE Step 2 score. Five points are awarded for interviews,
essays, and letters of recommendation. Additional “bonus
points” are awarded for prior military service research
publications. Applicants with prior military service in the
medical corps and medical service corps receive more points
than those with prior military service in nonmedical fields.
After scoring all applicants, the OML is created for applicants
in each branch of service. Similar to the ERAS match process,
applicants are matched according to programs’ rank list,
applicant’s preference, and the OML. The final results are
released in the middle of December.
Army and Air Force applicants, unlike the Navy, are
selected for categorical orthopedic residency positions. Thus,
once selected for the residency position, the trainee does not
need to reapply for orthopedic residency following orthopedic
internship. In the Navy, however, applicants are selected for
noncategorical orthopedic internships. As medical students,
Navy applicants are selected for orthopedic internship.
During the intern year, Navy orthopedic interns apply to the
JSGMEB for orthopedic residency. These applicants compete
for orthopedic resident positions against interns as well as a
Graduate Medical Officers that have completed internship
and are serving in the Navy. Generally, each Navy orthopedic
residency program selects one intern to continue into
residency without doing a GMO tour. From year to year, the
number of interns selected to pursue orthopedic residency
without completing a GMO tour is highly variable.
A small number of students apply for and are granted

educational deferment or funded positions to attend civilian
orthopedic residency. This track is extremely rare in the Army
but is more common in the Air Force and Navy. The number of
civilian-sponsored resident spots is extremely variable based
on the projected needs of the military, but annually ranges
from zero to five in the in Navy and Air Force. The applicant
should understand that differences in the service obligation,
pay, and benefits before electing for deferment. Because
some applicants may be selected for civilian orthopedic
residency, interested medical students should apply for and
arrange interviews at civilian programs. Many students prefer
to arrange interviews for late December and January, to
optimize the interview or cancel interviews, after the results
of the JSGMEB are released.
FELLOWSHIPS
Residents seeking orthopedic fellowship positions must be
approved by the JSGMEB and accepted by the fellowship
program. The first step in the application process is to apply for
fellowship approval to the JSGMEB. Similar to the orthopedic
residency application, the fellowship application is due to
the JSGMEB by mid-October and results are released by
mid-December. Often simultaneously applicants apply to the
civilian fellowship specialty programs of interest. If approved
by the JSGMEB, applicants interview and compete for the
desired fellowship programs. Upon selection for fellowship,
the applicant will incur two years of additional obligation for
each year of fellowship training.
The Army, Navy, and Air Force all provide fellowship
training for all orthopedic subspecialties. Not all subspecialty
training positions are offered every year, however. The
available fellowship programs are determined each year
based on the projected needs of the military. For example,
if you are an Army fourth-year resident interested in total
joint arthroplasty, but all the major military medical centers
have the maximum number of fellowship trained total joint
surgeons, a fellowship in adult reconstruction will not be
offered. With the exception of two Army fellowship programs
discussed below, all orthopedic fellowships are conducted at
civilian fellowship programs.
The Army has two fellowship programs in hand surgery
and orthopedic sports medicine. Army applicants seeking
specialty training in hand surgery or sports medicine apply
to these programs through the JSGMEB. The Walter Reed
Hand Fellowship is located at Walter Reed National Military
Medical Center. Each year two fellows in hand are selected
and they alternate training between 6 months at Walter Reed
and 6 months at the prestigious National Ray Curtis Hand
Center at Union Memorial Hospital in Baltimore, Maryland.
The John A. Feagin, Jr., Sports Medicine Fellowship at West
Point is an extremely competitive fellowship that selects two
applicants annually. The John A. Feagin, Jr., Sports Medicine
Fellowship is among the oldest and most distinguished
sports medicine fellowships in the country. Fellows have the
unique opportunity to care for a large population of Division
I athletic teams at West Point. Additionally fellows train at the
esteemed Hospital for Special Surgery in New York City and
have the opportunity to do traveling elective rotations at their
programs of interest.
references
1. Schoenfeld AJ. Orthopedic surgery in the United States Army:
a historical review. Military medicine. 2011;176(6):689-95.
Epub 2011/06/28.
2. Owens BD, Kragh JF, Jr., Wenke JC, Macaitis J, Wade CE,
Holcomb JB. Combat wounds in operation Iraqi Freedom
and operation Enduring Freedom. The Journal of trauma.
2008;64(2):295-9. Epub 2008/02/28.
3. Owens BD, Kragh JF, Jr., Macaitis J, Svoboda SJ, Wenke JC.
Characterization of extremity wounds in Operation Iraqi
Freedom and Operation Enduring Freedom. Journal of ortho
paedic trauma. 2007;21(4): 254-7. Epub 2007/04/07.
4. SalaryQuest. www.salaryquest.com. 2010 data.
5. All military pay information was obtained from www.military.
com. 2010 data
Index
Page numbers followed by f refer to figure and t refer to table.
A Benefits of away rotations 37

Academic Board scores 84
Orthopedic Programs 50 Bone fractures, treatment of 2
versus Community Booking your
Orthopedic Programs 74 flights 62
Acceptance program, supple- hotels 62
mental offer and 77, 80, 85 Bread-and-butter 77
Accreditation Council for
Graduate Medical
C
Campbell’s operative orthope-
Education 124, 152
Acting internship 51 dics 134
Adult reconstruction oncology 157 Canadian
Air force 184 Medical
Alpha omega alpha 50 Graduates 166
honor medical society 17 Protective Association 176
Anesthesia for surgery, develop- Orthopedic Surgery
ment of 5 Residents 165
Ankle 157 Resident Matching Service
Applicant 165
document tracking system 54 Case report studies 94
early registration deadline 79 Challenges during residency 121
Application process 49, 154 Choosing where to apply 149
Army 184 Clinical rotations 21
Arthroscopy Association of North CMG applicants 170
America 148 Cody See Eisenhower army
Attitudes toward authority 123 medical center
Away rotations and electives 33 Community-based programs 76
Conferences and skills lab resi-
B dency 144
Basic Curriculum vitae 14, 33, 52, 94
allowance for housing 180 Customs 123
science
courses, mastering and D
acing 10 Deadline for registration and ROL
research 93 certification 79
Dean’s office workstation 52, 53 G

Dislocations, treatment of 2 Gallabu 2
Diversity advisory board General
of American Academy of medical officer time 183
Orthopedic W
surgery 84
Surgeons 113
Grade point average 10
E Graduate medical education
Eastern time 84 application information
Educational commission for 191t
foreign medical graduates Gynecology 24, 35
155
Eisenhower army medical center H
187 Health
Electronic residency application Care System, Canadian 165
service 52 education consortium, San
Enneking orthopedic oncology Antonio uniformed
course 188 services 185
Ethnic Professions Scholarship
composition of orthopedic Program 182
surgery residents from sciences, uniformed services
1996 to 2009 113f university of 182
minority residents 123 Services Professional
Ethnicity 105 Scholarship Program
Externship performance, evalua- 191
tions of 104
Hip and knee Surgeons,
Extra sleep 131
American Association of
Extracurricular activities 18
147
F Home vs away electives 34
Factors to consider
in ranking programs 72
I
IMG applicants 171
when taking year off 96
Federal licensing examination Important dates for military-
155 match 192t
Fellowship planning 141 Institutional review board 142
Field of orthopedics 2 Instructional course lectures 145
First Interaction, methods of 123
aid 15 Intern year 129
year of medical school 50 Internal medicine 35
Foot 157 International
Fourth year of medical school english language testing
52, 57 system 168
Index 201
medical early in year, third year of
education directory 168 57
graduates 16, 83, 155, 166 for research, taking an
Interviews 66, 160 year off during or
and preparations 59 after 92
day 65 mid-late June, third year
preparation 62 of 57
schedules 66 personal statement 54
second year of 13, 51
J third year of 51, 57
Junior
student performance evalua-
resident, characteristics of
tions 52
successful 135
Military
year 132
candidates 179
K incentives 180
Knee injury 2 medicine, history of 179
Küntscher’s technique 6 pay 180
service 181
L Modern surgery, father of 3
Lateral Musculoskeletal
decubitus 153 Matching Program,
parapatellar arthrotomy for combined 148
knee 153
oncology 157
Letters of recommendation 43,
tumor society 147
55
Lifestyle considerations 122 N
Nation’s population 103
M
Match results information 77 National Resident Matching
Medical Program 22, 52, 67, 71, 148
center, madigan army 188 policies 67
college system 71
admission test 49 Naval medical center
Association of American Portsmouth 189
105 San Diego 190
Council of Canada Evaluating Navy 184
Examination 168 Netter’s concise orthopedic
education, continuing 145 anatomy 37
Examiners, National Board of NRMP
16, 155 fellowship match 157
school match 71
and application process, participating program 82
preparation efforts orthopedic surgery program
during 115 91
O programs 56, 64
Obstetrics 24, 35 english-speaking 167t
Operating room, observation military 184, 184t
in 129 selection process 22
Operative experience 157 rotation 35
Organizations and clubs 18 selection process in 104
Orthopedic 37, 41 Society, J Robert Gladden 115
anatomy foundation of 134 surgeons 56
application process 147 American Academy of 113
Association, British 5 deployments for board-
basic science research 93 certified 183
electives 43
surgery 14, 73
play 33
aspirations 117
focused 87
community 113
history of 1
competitiveness of 61
injuries
treatment of 2 during World War I,
volume of 5 department of
interest groups 19 military 179
in-training examination 139 guide for women in 114
junior resident in 133 lack of diversity in 104
knowledge 157 positions 86
oncology 148 programs 59, 60
programs 71 residencies 23, 103
applicants to 104 success during 129
ranking process 71 Osteologia nova 4
related research 92 Osteopathic
project 30 Association, American 58,
residency 61 79, 117
in Canada 165 Medical Examiners, National
application 166 Board of 53
deciding on residency
172 P
interviews 171 Pediatric 24, 35, 157
introduction 165 surgery 130
matching 174 Personal statement 52, 54
ranking 174 Physician assistants 40
second iteration 175 Program director’s workstation
statistics for year 2012 53
170
national capital consor- Q
tium 184 Quota change deadline 79
Index 203
R Shadowing physicians 19
Rank Shoulder injury 2
list 162 Soap 84
order list details 85
certification deadline 79 options 86
entry begins 79 process 88
Religion 123 Social
Remains of neolithic people 1 activities 18
Research 142 events 64
before and during residency readjustment rating scale 121
91 Special topics during residency
during residency 96 139
in residency, selection crite- tests 139
ria importance of 159 Spinal column injury 2
involvement 30 Spine 157
track 98 Sports 157
types of 93 Medicine
Reserve officers training corps American Orthopedic
191 Society for 148
Residency father of 2
achieving success during 124 Statistics 105
applicants timeline 56 for year 2012 170
life in Canada 176 gender 105
programs, application to 30 race 105
Resources available for female Staying in touch after interview
and minority medical 67
students 112 Steps in eras process 54
Rotations in orthopedics 41 Strategy for residency applica-
Ruth Jackson orthopedic society tion process 108
114 Stressors on
female residents 121
S racial 123
San francisco match system 148 Striking in orthopedic surgery
Scramble period 81 103
Selection Subinternship See Acting
criteria keys to success in internship
residency 157 Successful interns, characteris-
process, application and 191 tics of 132
Senior Supine See Lateral decubitus
level resident 136 Surgery of hand, American
resident, characteristics of Society for 148
successful 138 Surgical intensive care unit 130
T V
Test of VA system 75
english foreign language 168 VDD program, matched 81
spoken english 168 Violations
Third-year orthopedic surgery during match week 81
electives 30 examples of 80
Trauma 157 Visa qualifying examination 155
surgery 37
Tripler army medical center 187 W
Walter Reed National Military
U Medical Center 184
Undergraduate years 49 What makes good
Unicondylar knee arthroplasty, intern 130
cases on 153 junior resident 133
United States Medical Licensing What you do not match 83
Examination 10, 21, 33, When away rotations 41
51, 109, 155 When to schedule electives 35
USMLE Where away rotations 39
examinations 11 William Beaumont Army
practice questions 16 Medical Center 186
preparation, second year of Withdraw deadline 79
13 Women and minority students
review books and preparation interested in orthopedic
courses 15 surgery 103

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Orthopedic

Javad Parvizi MD FRCS

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd

Headquarters The views and opinions expressed in this

Orthopedic Residency Guide

I want to dedicate this book to residents in orthopedics for their

Kasra Ahmadinia MD Major Melvin Helgeson MD

Javad Parvizi MD FRCS Jonathan Streit MD

Applying for orthopedic surgery residency training is very compe-

work hourshave tightened. Case logs, milestone reporting, and

Orthopedic surgery continues to be one of the most sought after and

I would like to express my sincere gratitude to many great individuals

4. Away Rotations and Electives 33

11. Success during Orthopedic Surgery Residency 129

• Intern Year 129

12. Orthopedic Fellowship Application Process 147

In the last few decades, orthopedic surgery has emerged to

not fully, illustrates the level of difficulty for gaining acceptance

procedures such as arthroplasty have increased, and will

The history of orthopedics dates back to the stone age when

In 1900 BCE Babylon, the code of laws regulated

modified surgical techniques, including the use of tourni-

are credited by some as being the men who expa­nded ortho-

6. Riedman SR. Masters of the Scalpel: The Story of Surgery.

Congratulations on making it into one of the most competitive

when you will question the purpose of studying certain sub-

MASTERING AND ACING THE

method solidifies newly learned material. Indeed, it is the key

SECOND YEAR OF MEDICAL SCHOOL AND

two and has a format similar to that of Step 1; it assesses your

USMLE REVIEW BOOKS AND

Besides review books, there are several USMLE prepara-

USMLE PRACTICE QUESTIONS

ALPHA OMEGA ALPHA HONOR

For addi­tional information regarding AOA, visit their website:

ORGANIZATIONS AND CLUBS

Shadowing simply means volunteering to follow a physician

to specialize—it is best to see and experience them first hand

It is essential to know that in the orthopedic resi­

care for your patients. The prevalence of chronic, debilitating

KEYS TO SUCCESS DURING

these data ready to present. Each specialty and service has

•• Be a team player. The field of medicine has progre­ssively

APPLICATION TO RESIDENCY PROGRAMS

USMLE STEP 2 CLINICAL KNOWLEDGE

CV can match once they demo­nstrate excellent drive, work

Home vs away electives

When to Schedule the Electives

Rotations in the middle of the academic year also have

BENEFITS OF AWAY ROTATIONS

into a residency program. By getting to know the faculty and

WHERE TO DO AWAY ROTATIONS

There are numerous opinions on where to do away rotations.

make him or her more memorable when the department sits

WHEN TO DO AWAY ROTATIONS

be slightly less competition for good cases, call, and attention

HOW MANY AWAY ROTATIONS?

After getting affirmation from letter writers that they

Acceptance into a competitive residency such as orthopedics

Applicants’ activities and preparation for medical school

First Year of Medical School

Second Year of Medical School

Third Year of Medical School

are credited by some as being the men who expanded ortho-

For additional information regarding AOA, visit their website:

It is essential to know that in the orthopedic resi

•• Be a team player. The field of medicine has progressively

CV can match once they demonstrate excellent drive, work

In this chapter, we provide you with essential information on

In general, considering the competitiveness of orthopedic

March 17, 2014 ● Applicant matched and unmatched infor

Figure 4 depicts recent trends in the racial/ethnic compo

and/or a racial minority to be a beneficial and attractive attri