Given osteopathic medicine’s emphasis on the musculoskeletal system, it isn’t surprising that many osteopathic medical students are interested in orthopedic surgery. The student chapter of the American Osteopathic Academy of Orthopedics (AOAO) has nearly 800 members, says Lee Vander Lugt, DO, the AOAO’s executive director.
Shaun Notman, OMS IV, for one, chose to attend osteopathic medical school specifically to become better prepared for this specialty. “I knew I wanted to be an orthopedic surgeon—that’s the main reason I went to a DO school,” says Notman, who attends the Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, Fla.
As a career, orthopedic surgery holds many attractions. Burdened by student loan debt, some individuals may be drawn to the field for the pay. Tied with radiologists as the top-earning medical specialists, orthopedic surgeons make $315,000 a year on average, according to a 2012 Medscape survey.
But the potential for high income should not be the main motivation for pursuing this specialty, warns Paul J. Drouillard, DO, the program director of the AOA-approved orthopedic surgery residency at Garden City (Mich.) Hospital. “If you’re thinking of going into orthopedic surgery for the money, you should consider becoming a venture capitalist instead,” he says. “If money is the driving force, you are going to be unhappy.”
Orthopedic surgery is a fulfilling field for numerous reasons, Dr. Vander Lugt says. “You get to work with your hands. You get to work with various instruments. And you can help people get better and get back to work,” he explains.
The specialty appeals to results-driven individuals rather than those who like to puzzle over diagnoses or provide longitudinal care lasting years.
“There is an instant gratification that comes from repairing someone rather than taking care of someone with a chronic condition like high blood pressure,” points out Joel L. Rush, DO, who directs the AOA-approved orthopedic surgery residency at Broward Health Medical Center in Fort Lauderdale, Fla. “I especially enjoy orthopedics because I’m a tool junkie. I love that I get to use really cool nitrogen-powered saws and all manner of drills, chisels and hammers.”
Those who are drawn to orthopedic surgery over other surgical specialties often have personal experience with orthopedics as a patient.
“When I was 16, I tore the meniscus in my knee while wrestling. I could tell that the physician who took care of me loved his job,” Dr. Drouillard remembers.
Notman also became aware of the specialty as a teenage athlete who tore his knee’s anterior cruciate ligament twice. Like many who are attracted to orthopedics, he has a twin passion for sports medicine, which he’d like to subspecialize in.
Most of all, Notman loves orthopedic surgery’s creative side. “Orthopedic surgery isn’t as algorithmic as other specialties. There isn’t one single correct answer for every problem,” he explains. “Because half a dozen surgical techniques can be used to fix most orthopedic problems, the field is very artistic.”
But this intensely competitive specialty cannot accommodate everyone it captivates. With dozens—in some cases, hundreds—of applicants per position, all 40 AOA-approved orthopedic surgery residencies fill easily. Some programs limit themselves to candidates who rank in the top 10% of their class and score at least in the 90th percentile on the Comprehensive Osteopathic Medical Licensing Examination—USA (COMLEX-USA), Dr. Vander Lugt says.
Orthopedic surgery residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) are rarely a viable option for DO graduates because of demand by MDs for the highly competitive slots, Dr. Vander Lugt says. Only five or so DO students each year match into ACGME-accredited orthopedic surgery residency programs.
Both AOA-approved and ACGME-accredited residencies in orthopedic surgery take five years to complete. Most candidates match into these programs in their fourth year of medical school, but it isn’t impossible to snag a position later.
New AOA-approved programs sometimes open after the AOA Match takes place. And as many as a dozen orthopedic surgery residents are let go each year from osteopathic programs, which can free up spots for other trainees, according to Dr. Vander Lugt. “When residents are let go, it is generally because they don’t work well with others,” he says.
Tough but not rigid barriers
Notman knows firsthand how hard it is to get into an orthopedic surgery residency. “Unfortunately, I didn’t match into an orthopedics program this year,” says the immediate past president of the Student AOAO. “So I took a traditional rotating internship position and will be applying to an orthopedics program next year.”
A self-described “gunner,” who has tried to shine on every orthopedics rotation by showing initiative, working tirelessly and being exceptionally well-prepared, Notman attributes his failure to obtain a position to middling COMLEX-USA scores. “My grades are good and competitive and my knowledge of orthopedics is second to none compared with many students I rotated with,” he says. “But my board scores are average for a med student—strong enough to get many other residencies but not quite what I needed for orthopedics.”
Notman had hoped that his many extracurricular activities related to orthopedic surgery would help his chances. Besides being a student leader in the specialty, he has done research and has clinically relevant volunteer experience.
Learning from his mistakes, Notman says the best advice he can offer orthopedic surgery hopefuls is not to overextend themselves to become or appear well-rounded. “You can involve yourself in organizations, do research and volunteer work, and travel to conferences. But be sure this does not come at the expense of the significant amount of time needed to study for classes and the boards,” he says.
Residency directors agree that board scores do matter a lot because they indicate how well candidates would likely perform on the orthopedic surgery board-certification examination after residency.
“Most of the people we interview have scores above the 90th percentile,” says program director Homer C. Linard, DO, who receives more than 100 applications for three annual orthopedic surgery residency positions at Botsford Hospital in Farmington Hills, Mich. “Have we taken anybody with a score less than that? Absolutely. We also consider a candidate’s personality. Is he or she a team player? Will the candidate fit in?”
Receiving approximately 120 applications annually, Broward Health’s Dr. Rush selects 22 candidates to interview. Of this year’s interviewees, 85% had COMLEX scores at least in the 85th percentile. “That being said, we have selected a resident who has a percentile score in the upper 70s,” he says. “That person’s board scores may not be as great, but he or she is well-liked and has everything else we are looking for in a candidate. So not having stellar board scores doesn’t mean you won’t be considered.”
Garden City Hospital’s Dr. Drouillard is even more forgiving about less-than-exceptional COMLEX scores. “Of course we want someone who is bright,” he says. “But a willingness to learn is more important to us than superb scores.”
Besides academic prowess, orthopedic surgery candidates need the right attitude and aptitude for an intense profession that pivots on teamwork and manual skills. Such traits cannot be gauged by application packets alone.
Most residency directors in orthopedic surgery say it is impossible to evaluate candidates’ initiative, diligence, interpersonal skills and manual dexterity without observing applicants in a clinical setting. Rotating with the desired program is, therefore, a must.
“It’s rare for us to take on residents who have never rotated with us,” Dr. Drouillard says. “For that to occur, someone has to have a spectacular interview, as well as spectacular credentials.”
For Dr. Rush, rotations are essential to assess candidates’ work habits. “Demonstrating a good work ethic means doing the tasks that are assigned plus volunteering to do extra tasks related to their interests,” he says. “It’s taking the initiative by saying, ‘I’m going to look this up and tell you about it tomorrow.’ ”
Dr. Rush recalls one student who had great credentials but blew his rotation. “He thought he was a shoo-in. But when he was on service, he was lazy,” Dr. Rush remembers. “He would be looking at football scores while other people worked. And his notes weren’t thorough. So I told him, ‘The residency was yours to take, but you didn’t perform. You’re not going to be part of our team.’ ”
Dr. Linard also places a premium on rotations. “Over the years, 80% to 90% of the residents we’ve taken on have been people who’ve rotated with us,” he says.
Dr. Linard likes aspiring residents to serve month-long rotations at Botsford between July and October, right before the interview season in late fall. “I don’t like two-week audition rotations,” he says. “How much can a student learn in two weeks? Are you just here for me to meet you, or are you actually here to learn some orthopedics?”
During their orthopedics rotation at Botsford, students spend two weeks in surgery, one week in the emergency department and one week in the office. “They learn aspects of the physical examination of an orthopedic patient,” Dr. Linard says. “They learn some of the tests we do to make a diagnosis. And working in the emergency department, they have the opportunity to do some sewing and put on casts.”
Demands and rewards
As with all surgical specialties, orthopedic surgeons need good hands, coordination and visual-spatial acumen. Computer simulation programs have been developed to assess these skills in students, Dr. Vander Lugt says.
Stamina and strength are also important in orthopedic surgery, a physically demanding specialty. But brute strength isn’t essential, as evidenced by more and more women entering the still mostly male field.
“We have two women in our program now, and I’m just 5 foot 7—not a big guy,” Dr. Rush says. “For me to reduce a hip is a lot of work, and it’s going to be harder for a woman who is 5 foot 3. But in this field, you learn how to use your body size appropriately to do what you have to do.” More petite trainees sometimes choose to subspecialize in hand surgery, he adds.
The work hours of orthopedic surgeons are also very demanding, particularly in the early years after residency. “You have to assume that in your first few years of practice, you will be busy. You will be working all the time. And you’re not going to see your family much,” Dr. Rush says. “I joke with my residents about the 80-hour work week rule.
“They don’t understand that when they get to go home at 9 a.m. and I’ve been up with them all night, I still have the rest of my office day ahead of me.”
On the other hand, says Dr. Rush, orthopedic surgeons can choose a subspecialty and practice type to mesh with their lifestyle priorities. For example, hand surgeons have more defined hours than trauma surgeons. And orthopedic surgeons who are in group practices or employed by hospitals take much less call than those in solo practice.
Offering bright career prospects, the field of orthopedic surgery is growing rapidly, as baby boomers age and need new knees and hips and severely injured veterans need prosthetic legs and arms. With amateur athletes testing the limits of their endurance and bravery in marathons, triathlons, snowboarding and newer extreme sports, fractures and other sports injuries increasingly require the attention of orthopedic surgeons.
As a medical specialty, orthopedic surgery remains seductive to students such as Notman, who is not giving up his dream of landing a residency, despite the reduced odds of doing so from a rotating internship. For seasoned orthopedic surgeons, ever-evolving technologies and a tremendous sense of accomplishment keep the field fresh and exciting.
“I have been here 22 years and still love what I do,” says Garden City Hospital’s Dr. Drouillard. “What I love most about orthopedic surgery is that probably 95% of the time people have good outcomes. Most of our patients are really happy.”