The short answer is, no. You don't NEED to do a fellowship when you're done. I haven't seen the numbers which you quote (BTW, what about the other 13% of people?), but it's not surprising. I think most people who train at large academic institutions will do fellowships.

Basically, the reasons to do fellowships are highly variable. At Case, there has not been a resident go straight into practice w/o fellowship in like 15 years! There's a huge "internal" push to do fellowship here because we're a large academic institution that prides itself on producing academic physicians (BTW, all of our attendings did fellowships). So if you want to get a hard core academic job, are on the chairman track, or want to do big time research, it probably is important to do a fellowship. Other people do fellowships to become more proficient at a particular field of interest or fill a deficiency for something they didn't pick up in residency (i.e. a sports fellowship to become proficient in shoulder arthroscopy). Then you have people like me who want to to COMPLEX stuff in a defined subspecialty (i.e. complex spinal deformity cases, multiligamentous sports injuries, pelvic/acetabulum reconstruction, or revision joints). Furthermore some issues in orthopaedics, i.e. Tumor, peds, and hand probably shoudn't be undertaken in practice w/o a fellowship in the respective field. For instance, a generalist can have a sports, joints, or even trauma heavy general practice w/o having done a fellowship in any of those fields. With that said, I plan on doing a sports fellowship because I love sports and want to be "the man" someday for some college or professional team. Will I do some joints, yes. Will I do some trauma, yes. Will I do some spine, no . . . . .but training at case I could if I wanted to.

Also I look at it like this, an additional year of training couldn't hurt, right? it probably will make you more marketable no matter what type of practice you do, community, academic, or somewhere in between. And it's probably better to do fresh out of residency when you're used to living like a resident. After all, you never know where you're gonna end up down the road and it would be hard to go back after living the attending life. Hope this helps. It's just MY opinion.

Agree with above...

also find the statement "want to be 'the man' someday for some college or professional team" amusing. It's funny how sports docs actually interpret it that way...as if sitting on the sidelines and having to take crap from some 20 year old with a big ego is fun.

Yeah, but who else gets paid the big bucks to have the best seats in the house? It's all about the perks. Not a bad "job" if you ask me. And besides... chicks dig it.

Hey bone_jock... when you're "the man" score me some tix, OK?

"but who else gets paid the big bucks to have the best seats in the house?"

I think being obligated to go to these games takes some of the fun out of it. Sure, if you're the Lakers physician it's fun. But chances are you won't be...and if you are, chances are the athletic trainer, coach and all the assistant coaches make as much money if not more than you do.

If you've ever owned season tickets for anything, you'd realize that after a while, going to the games becomes a chore. So you start giving tickets away to your buddies. There's not enough time to go to all the games. But as a team physician, you have to go. Remember, you can't even have a beer at the job.

I can't imagine going to a game and not drinking. It's unAmerican.

From my admittedly limited exposure, it is definitely not necessary to do a fellowship to get a "good" private practice job. I know people who graduated from my program and other programs who went directly into private practice. The places they were going to practice ranged from towns with populations less than 20,000 to cities nearing a million. However, I have no doubt that the job market for general orthopods is much different in a town of one hundred thousand than it is for a city of one million. I think bone jock raises excellent points as usual, but I think it is important not to get caught up in the hype that you "have" to do a fellowship. Ask around about fellowship training and you will find out that a significant number of people do sports fellowships. I dont claim to speak with absolute authority on the following point, but I am willing to guess that even fellowship trained orthopaedic surgeons, especially some in sports, end up having a practice that bears a quite striking resemblance to a general orthopaedic practice. As bone jock said, an extra year definitely can not hurt, but it may also not be necessary if you want a general orthopaedic practice.

In addition, keep in mind that there is definitely a different training culture or focus at various residency programs. Some places will probably have the expectation that you will do a fellowship after residency whereas other places may focus on training general orthopaedic surgeons who may be equally as likely to go into fellowship as they are to go straight into practice. Although I am sure you could find numerous people who would argue that one philosophy is better than the other, I personally think it is simply dealer's choice and you just have to choose to train the way that best fits your personality and long term goals.

All of the above is simply antecdotal or opinion, so dont stop asking people the question. You could probably get a hundred different answers to this question, but the info will make you better prepared to make the right choice for you. Good luck.

All good points made above......

Don't be fooled by the numbers. As alluded to above, it is simply not enough to look at the percentage of people doing fellowships to figure out how much general orthopedics is going on in this country. You would also have to look at individual practices to determine such a number. Every time a sports trained surgeon does a total knee, or every time a "hand surgeon" does an ankle fracture, etc, those become general orthopedic cases. There are surgeons who end up doing little to none of what their fellowships focused on. The point is the percent of an individual surgeons' practice devoted to their subspecialty varies dramatically. If, for example, the average fellowship trained surgeon spends 50% of their practice on their subspecialty and roughly 2/3 of residents complete fellowships, then only about 1/3 of the orthopedics being performed is truly "subspecialized". As pointed out above, a large majority of fellowships being completed are in sports medicine, ( I have read around 30% of all fellowships) and while a few of these (such as Bone Jock) will find themselves in practices involving >90% sports, the majority will likely have more of a mix.

Another point not mentioned. I would disagree with the statement that "another year of training cannot hurt". I have spoken to a few residents who have completed a fellowship only to accept a job in a more general environment. While they were happy with their fellowship, they felt as though it was not necessary for their practice. In some ways they felt as though their skills in cases outside the scope of their fellowship suffered somewhat.

In terms of marketability, a fellowship may help in some more saturated areas, but orthopedics is so heavily recruited right now that many general opportunities exist in even major metropolitan markets. I am getting 2-3 emails a day and around 3-4 letters a week from recruiters, many with multiple opportunities, and I see general opportunities available more than any one subspeciality - in all market sizes (although a trend toward small to midsize).

That being said, there has certainly been a trend toward subspecialization. There are many good reasons to pursue a fellowship as mentioned above. If possible, it is nice to choose a residency which will provide you with adequate training to jump right into a private general practice, even if you have the intention of subspecializing. Situations and goals can change dramatically over 5 years and it is nice to have options.

If possible, it is nice to choose a residency which will provide you with adequate training to jump right into a private general practice, even if you have the intention of subspecializing.

I think that is key, although difficult to figure out as a medical student dealing with a rank list. Remember, a fellowship is nothing more than extra practice. You don't get some special certificate that says you are able do certain procedures while others cannot. You don't get another license. You just get a year of extra cases, focusing in on a certain subspecialty.

Despite what many may think, there are plenty of programs out there that will not adequately prepare you for practice. And from those programs a fellowship is absolutely necessary. On the other side, there are programs where you will operate so much that you will feel comfortable going right out into private practice. Programs do exist where you will do enough cases that you basically did mini-fellowships during residency.

Keep your eyes open when you guys are out there applying/interviewing. Ask as many questions as you can about case load. More importantly, look at the number of residents in the program and the number of rooms they have running each day. It will give you a decent idea of how exposed the residents are to cases as primary surgeons, rather than as retractors. You still need a good balance of academics and case load; too heavy on either side will tip the boat. But if I could choose I would take the program a little heavier on the operative side, because you can read at home.

Actually young grasshopper. . . . . .

There is a certificate that may come into play down the road. A little something called the CAQ (certificate of added qualification). Right now, only Hand has it, and sports medicine may be soon to follow. This doesn't necessarily prevent you from doing certain procedures, but it may prevent you from working at certain academic institutions or joining certain subspecialty societies/organizations. It may also open you up to litigation if you perform a complex case that you weren't "certified" to do. . . . .whether you're CAPABLE or not.

And don't get me wrong. I'm not saying that fellowships are a must. To each his/her own. Do what's right for you. But I am saying that if you want to end up in big academics or do the really cool/difficult/revision cases in a respective subspecialty you probably need a fellowship. The big 3 hospitals in Cleveland - Case, The Cleveland Clinic and Metro (county/trauma hospital affiliated with Case) all are staffed COMPLETELY by fellowship-trained orthopods. And look at it this way, "it's better to have and not need than it is to need and not have." Another point is that you don't have to be Board Certified to practice orthopaedics in a lot of community places, but no one will argue that you're better off having it. Ok so maybe that's apples and oranges =). Just a little something to think about. With that said we all know "fellowship-trained" orthopods who don't know their elbow from their a-holes. On the other hand we have a trauma trained attending who can do ACL's, PCL's, scopes and PLC reconstructions like a sports trained doc.