The PDF of the article you requested follows this cover page. This is an enhanced PDF from The Journal of Bone and Joint Surgery 2008;90:1375-1384. doi:10.2106/JBJS.G.01582 J Bone Joint Surg Am.William N. Levine, G. Paul DeRosa and Serena S. Hu Christopher D. Harner, Anil S. Ranawat, Muriel Niederle, Alvin E. Roth, Peter J. Stern, Shepard R. Hurwitz, Match Necessary? Is It Possible?AOA Symposium. Current State of Fellowship Hiring: Is a UniversalThis information is current as of June 2, 2008 Reprints and PermissionsPermissions] link. and click on the [Reprints andjbjs.orgarticle, or locate the article citation on to use material from thisorder reprints or request permissionClick here to Publisher Informationwww.jbjs.org20 Pickering Street, Needham, MA 02492-3157The Journal of Bone and Joint SurgerytheOrthopaedicforumAOA SymposiumCurrent State of Fellowship Hiring: Is a UniversalMatch Necessary? Is It Possible?*By Christopher D. Harner, MD, Anil S. Ranawat, MD, Muriel Niederle, PhD, Alvin E. Roth, PhD,P eter J . Stern, MD, Shepard R. H urwitz, MD, William N. Levine, MD, G. Paul DeRosa, MD, and Serena S. Hu, MDCurrently, approximately 90% of the 620graduating orthopaedic residents in theUnited States are planning on entering apostgraduate fellowship. Since January2005, two of the largest fellowship matchprograms, sports medicine and spinesurgery, were dissolved by the NationalResident Matching Program (NRMP)because of a gradual decline in partici-pation, leaving approximately 70% ofapplicants in a nonmatching, decentral-ized system. This leaves hand, shoulderand elbow surgery, and foot and ankle asthe only three orthopaedic subspecialtiesthat remain in some type of matchprogram, creating an extremely compli-cated hiring environment for all resi-dents. This paper focuses on the currentstate of fellowship employment andhiring in orthopaedic surgery in theUnited States, on the likely effects ofreinstituting a match, and on how thismight be accomplished. For this pur-pose, we present the results of surveys offellowship directors and residents that weconducted and we describe how thepresent market for orthopaedic surgeryfello ws resembles the market for medical*This report is based on a symposium presentedat the Annual Meeting of the American Ortho-paedic Association on June 13, 2007, in Asheville,North Carolina.Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants inexcess of $10,000 from the National Science Foundation (NSF) and the Sloan Foundation. Neither they nor a member of their immediate familiesreceived payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid ordirected, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofitorganization with which the authors, or a member of their immediate families, are affiliated or associated.1375COPYRIGHT Ó 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATEDJ Bone Joint Surg Am. 2008;90:1375-84ddoi:10.2106/JBJS.G.01582residents prior to the introduction of theNRMP1,2and how another fellowshipmarket has successfully reinstituted amatch after experiencing a comparablefailure3.We found that, in contrast toorthopaedic surgery fellowship pro-grams that use a match, programs insubspecialties presently not participat-ing in a match suffer from problemsoften seen in decentralized labor mar-kets. Interviews and offers come earliereach year and are extended over a lon-ger period of time. (In the economicsliterature, this is termed unraveling.)Employers or fellowship programs thenmake offers at different times, so thatboth sides face a thin market, in whichonly a subset of fellowships and candi-dates can be considered when decisionshave to be made. Ultimately, programsand applicants have to make decisionswith very little information about theiralternatives.To place the current situationfacing orthopaedic surgery fellowshipsin historic context, we briefly summa-rize how the NRMP arose to resolvesimilar difficulties in the market forresidents. We then document the cur-rent situation by presenting the dataof two online surveys administered bythe American Orthopaedic Association(AOA): one went to fellowship directorsand one went to residents participatingin the AOA Resident Leadership Forum.Both surveys reflect many of the prob-lems of the current decentralized pro-cess and how they impact residents andfellowship directors. We also presentthe unique experiences of the threeremaining subspecialties that currentlystill use a match: hand, foot and ankle,and shoulder and elbow surgery. Finally,we explore the available options to im-prove the current process using therecent experience of the reinstitution ofthe gastroenterology match as a poten-tial model.The NRMP and the History of theMarket for Medical InternsThe problems facing the current hiringmarket for orthopaedic surgery fellowsare hardly unique. They were antici-pated by the problems in the market forresidents that led to the creation of theNRMP1-4.In the early 1900s, the competi-tion among hospitals for interns (andamong interns for good internships) ledto internship appointments being madeearlier and earlier in a student’s medicalschool career. By the 1940s, appoint-ments were sometimes made two yearsahead of medical school graduation sohospitals had little information aboutthe student’s performance, and studentsfrequently had to accept or reject anoffer without knowing what other offersmight be forthcoming. This kind ofmarket unraveling, in which appoint-ments are offered earlier and morediffused over time, is found in otherprofessional entry-level labor marketsalso4. From 1945 through 1951, effortswere made to make appointments at auniform date, later in the students’medical school careers. But studentscame to be faced with offers having veryshort deadlines, again compelling manyto accept offers without knowing whatother offers might be forthcoming. Thisforced hospitals to scramble for avail-able students since, if an initial offer wasrejected, it was often too late to contactthe next most preferred candidatesbefore they had accepted another offer.The establishment of a centralizedclearinghouse, along the lines of whatbecame the resident match, was pro-posed as a way of alleviating this chaosand congestion