Editorial   |    
A Simple Formula for Continued Improvement in Orthopaedic Surgery Postgraduate Training: Courageous Leadership
Marc F. Swiontkowski, MD
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The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jun 01;90(6):1175-1175. doi: 10.2106/JBJS.H.00387
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We have enjoyed tremendous improvement in the quality of postgraduate education in orthopaedic surgery over the last three to four decades. This improvement has been an absolute necessity, given the rapid and complex technological and therapeutic expansion of our specialty. Gone are the days of the autocratic chief who hired and fired individuals on the basis of a personal whim and unwritten (and frequently unspoken) rules. As the role of our Orthopaedic Residency Review Committee has expanded within the Accreditation Council for Graduate Medical Education (ACGME), we have seen huge improvements in the processes that are used for interviewing and selecting resident candidates; in the methods that are used to provide residents with comprehensive didactic education through the application of core curricula; in the implementation of regular, transparent two-way evaluations of residents and educators alike; and in the counseling and educational processes that are used when the performance of residents and faculty is lacking. Although our specialty had grave concerns regarding the ACGME-implemented eighty-hour workweek, most educators believe (and the data support) that this change has benefited resident education and quality of life.
We now face another aspect of postgraduate education that needs our attention: the process of interviewing and selecting individuals for orthopaedic surgery fellowship training.
With the expansion of fellowship training, volunteer matching systems were attempted for most of our subspecialties. These attempts met with universal failure as individual program directors made the decision to violate the rules by pressuring those they believed were the best candidates with "exploding" offers ("Call me back within twenty-four hours or I will give the slot to someone else") and/or by moving up interview dates by months every year. Often these pressures were applied by the directors who thought that their programs did not have the strongest reputation, and nearly all program directors followed. In this issue of The Journal, Harner et al. detail the current situation within the field of orthopaedic surgery fellowship matching. They detail how the National Resident Matching Program (NRMP) arose to solve the identical problem with residency selection three decades ago. They instruct us with the efforts of the shoulder and elbow community, the foot and ankle community, and those outside orthopaedic surgery represented by the successful matching program within gastroenterology. While efforts are under way within some orthopaedic subspecialties, only a universal fellowship match will solve the problem for our resident candidates.
The American Orthopaedic Association, in its role as the organization for academic orthopaedic surgeons and leaders from all walks of orthopaedic practice, is in the ideal position to lead the effort. Establishing this match will also require leadership from our largest organization, the American Academy of Orthopaedic Surgeons, to actively support the initiative through the efforts of its presidential line and board of directors. The effort will succeed, however, only by courageous leadership from the presidential lines and boards of directors of all orthopaedic surgery subspecialties. All subspecialties must agree to adopt and abide by the new NRMP orthopaedic fellowship match. This simply means doing the right thing for a vulnerable population—our orthopaedic residents who are nearing the end of their training. They have been abused by the process as it presently exists, and, as they are our future lifeblood, now is the time to correct the situation, just as we did decades ago for a younger vulnerable group of medical students seeking an orthopaedic surgery residency.

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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