From Debt to Dollars: Assessing a General Surgeon's Career Value

INTRODUCTION

Surgical residents make decisions that may have a dramatic impact on career earnings based off conceptions regarding future income potential. This study examines the effect of debt burden, repayment plan, and practice setting on a general surgeon's career value.

METHODS

Debt levels, repayment plans, and practice setting were considered to model a surgeon's career value using net present value (NPV) across 35 scenarios. The NPV was calculated using salary, education debt, yearly spending, and a discount rate of 5%. Salary data were obtained from the Medical Group Management Association, student debt information from the Association of American Medical Colleges, and tax and household spending data from U.S. government records. Assumptions included no gaps in training, no prior debt, single-person household, and career duration of 35 y.

RESULTS

A general surgeon's salary adequately repays debt burdens from $100,000-$300,000 over 10-25 y, regardless of repayment plan or practice setting. Practice setting decreased career value for academic surgeons when debt burden and repayment plan were held constant: the NPV for an academic surgeon was $382,000 compared to $500,000 for a nonacademic surgeon with the same debt and repayment plan. Debt burden repaid through unsubsidized and income-based repayment plans reduced NPV for all surgeons, while subsidized plans increased NPV. The projected NPV for all scenarios ranged $2.35M-$2.87 M.

CONCLUSIONS

Though the modeled scenarios do not account for prior debt burden, major expenditures, or increases in yearly household spending beyond national averages, surgery residents should be aware that general surgery remains a financially feasible career.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

10 Year Analysis of Pediatric Surgery Fellowship Match and Operative Experience: Concerning Trends?

OBJECTIVE

This paper aims to evaluate the pediatric surgery training pipeline vis-à-vis the pediatric surgery match and operative experience of pediatric surgery fellows.

SUMMARY OF BACKGROUND DATA

Pediatric surgery remains a competitive surgical subspecialty. However, there is concern that operative experience for pediatric surgery fellows is changing. This paper examines the selectivity of the pediatric surgery match, along with the operative experience of pediatric surgery fellows to characterize the state of pediatric surgery training.

METHODS

The pediatric surgery fellowship match was analyzed from the National Resident Matching Program data from 2010 to 2019. Selectivity among fellowships was compared using analysis of variance with Dunnett test. Operative log data for pediatric fellows was analyzed using the Accreditation Council for Graduate Medical Education case logs from 2009 to 2019. Linear regression analysis was used to evaluate trends in operative volume over time.

RESULTS

Pediatric surgery had the highest proportion of unmatched applicants (47.2% ± 5.3%) and lowest proportion of unfilled positions (1.4% ± 1.6%) when compared to other National Resident Matching Program surgical fellowships. Accreditation Council for Graduate Medical Education case log analysis revealed a statistically significant decrease in cases for graduating fellows (-5.3 cases/year, P < 0.05). Total index cases decreased (-4.7 cases/year, P < 0.01, R 2 = 0.83) such that graduates in 2019 completed 59 fewer index operations than graduates in 2009.

CONCLUSION

Although pediatric surgery fellowship remains highly selective there has been a decline in the operative experience for graduating fellows. This highlights the need for evaluation of training paradigms and operative exposure in pediatric surgery to ensure the training of competent pediatric surgeons.

Early-Career Sports Medicine Surgeons Perform a Large Volume of Non-Sports Medicine Procedures: American Board of Orthopaedic Surgery (ABOS) Part-II Data Regarding Orthopaedic Surgeons Specializing in Sports Medicine

BACKGROUND

The purpose of this study was to utilize the American Board of Orthopaedic Surgery (ABOS) Part-II Case List database to (1) define the practice patterns of sports medicine-trained ABOS Part- II Oral Examination Candidates and (2) describe the frequency and practice patterns of individuals who are dual fellowship-trained sports medicine candidates.

METHODS

The ABOS Part-II Case List database was utilized to define all cases submitted by 3,298 applicants indicating completion of a sports medicine fellowship between January 1, 2003, and January 1, 2020. Cases were classified by subspecialty category and case type. The frequency and practice patterns of candidates pursuing additional fellowship training (i.e., "dual fellowship-trained") were recorded. Descriptive statistical methods were used to describe the annual and overall procedure volume and candidate case mix. Trends in the relative frequency of cases performed and fellowship training patterns were determined using linear regression analysis.

RESULTS

On average, sports medicine-trained candidates submitted 100.6 cases for review during the 6-month case collection period: 59.0 (58.6%) sports medicine/arthroscopy cases, 29.3 (29.1%) trauma/general cases, 4.5 (4.5%) adult reconstruction cases, and 7.8 (7.8%) "other" cases per candidate. Although candidates performed fewer total (r 2 = 0.84, p < 0.001) and sports medicine/arthroscopy (r 2 = 0.85, p < 0.001) cases over the study period, the proportion of sports medicine/arthroscopy cases did not change over the study period (p = 0.18). Dual fellowship training was indicated by 333 individuals (10.1%). The number of dual fellowship-trained candidates pursuing additional fellowship training in pediatrics and adult reconstruction increased over the study period, and the number of dual fellowship-trained candidates pursuing additional fellowship training in trauma decreased over the study period.

CONCLUSIONS

Early-career sports medicine candidates are likely to perform >40% of cases outside of the sports medicine subspecialty. Sports medicine trainees are increasingly likely to pursue a second fellowship in pediatrics or adult reconstruction.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Trends in Fellowship Training across United States Plastic and Reconstructive Surgery Academic Faculty

Plastic and reconstructive surgery (PRS) academic positions are more coveted each year. We aim to determine the requirement of fellowship training before PRS academic appointments.

METHODS

PRS faculty at U.S. academic institutions associated with the American Society of Plastic Surgeons were identified. Outcomes studied included integrated versus independent training, fellowships, gender, academic title, years on faculty, and publications before current hire.

RESULTS

Of the 1052 PRS faculty identified, 646 were included across 41 states and the District of Columbia. Seventy-four percent were identified as men (n = 477), and 26.2% (n = 169) identified as women. Academic faculty were significantly more likely to have completed fellowship before hire than not (p<0.0001). An integrated route of training was associated with higher odds of fellowship completion before appointment (OR = 2.19, 95% CI: 1.49-3.22). Odds of fellowship completion was significantly greater among faculty who graduated 5-10 years ago (OR = 2.55, 95% CI: 1.48-4.41) and within the last 5 years (OR = 1.93, 95% CI: 1.18-3.17). Professors were less likely to have completed fellowship training before appointment compared with assistant professors (OR = 0.51, 95% CI: 0.33-0.80). Regarding gender, number of prior publications, or completion of another degree, no significant difference was found between fellowship- and non-fellowship-trained faculty.

CONCLUSIONS

Although more plastic surgeons enter the field through a shortened integrated residency, the increasing demand for further subspecialization may cause significant challenges for upcoming graduates pursuing an academic appointment. Undergoing additional training considerably impacts social and financial decision-making early in surgical careers for newly graduated residents.

Trends in leadership at breast surgical oncology fellowships

Introduction

Breast surgical oncology is a defined sub-specialty of general surgery that focuses on the surgical management of breast disease and malignancy within a multidisciplinary context. The fellowship directors (FD) that lead these programs have been selected for their abilities. As programs do research to ensure proper training for the next generation of breast surgical oncologists, we wanted to look into the FDs responsible for their training.

Methods

The Breast Surgical Oncology care program list was compiled via the Society of Surgical Oncology and American Society of Breast Surgeons Accredited programs (n = 60). The demographic information that was of interest included, but was not limited to, gender, age, ethnicity/background, past residency training, past fellowship training, year graduated from residency and fellowship, year since graduation to FD appointment, time at institution till FD appointment, and Hirsch index (h-index).

Results

Data were collected on all 60 FDs. The average age of FDs was 52 years old, 27% of FDs are men and 73% of FDs are women. The average H-index, number of publications, and number of citations were 19, 67, and 2648, respectively. The mean graduation year from residency was 2003, and from fellowship was 2006; with a mean of 9 years post fellowship graduation until becoming an FD. The most frequently attended residency was Rush (n = 4), and the most common fellowships were Memorial Sloan Kettering (n = 8), MD Anderson Cancer Center (n = 7), and John Wayne Cancer Institute (n = 4). Nine of the FDs stayed at the same institution after doing both residency and fellowship there (15%).

Conclusion

This is the first study to examine the demographics of those in FD positions in Surgical Breast Oncology, which is a relatively young fellowship. We found that FDs in Breast Surgical Oncology are defined by their high output of research. This qualification may be why the average age, and the number of years to FD are higher compared to other specialties where this research has been undertaken. Initial evaluation of FDs suggest more diversity in this field is needed. Further insight into the leaders training our next generation of surgeons is warranted.

Transition to Independent Research Funding Among National Institutes of Health K Grant Awardees at Departments of Orthopaedic Surgery

BACKGROUND

The National Institutes of Health (NIH) supports mentored research career development awards (K awards) to increase the pipeline of independently funded scientists. This study analyzed the portfolio of K grants that were awarded to orthopaedic surgery departments and characterized the factors that were associated with successful transition to independent NIH research funding, including R01 grants.

METHODS

This was a retrospective cohort study of K-award recipients in orthopaedic surgery departments in the United States from 1996 to 2018. A query was performed on the NIH Research Portfolio Online Reporting Tools (RePORT) database for NIH grants that were awarded to departments of orthopaedic surgery, general surgery, otolaryngology, obstetrics and gynecology, ophthalmology, and urology. Rates of transition to independent research funding were compared by specialty for K grants that were awarded from 1996 to 2011. The percentage of faculty with mentored research career development awards and the return on investment (ROI) were calculated. An internet and Scopus (Elsevier) database search determined the investigator characteristics. The factors that were associated with successful transition to independent funding were determined via chi-square and unpaired t tests.

RESULTS

Sixty K-award recipients were identified in orthopaedic surgery departments. Most were men (77%) and research scientists (53%). Fifty percent of the K-award recipients transitioned to independent research funding. Research scientists had the highest rate of transition to independent research funding (71%, p = 0.016) relative to clinicians (0%) and orthopaedic surgeons (40%). Higher levels of publication productivity were associated with successful transition to independent research funding. Similar rates of transition to independent research funding existed among surgical specialties (p = 0.107). Orthopaedic surgery had the lowest percentage of faculty with a K award (1.4%) but had the highest ROI (198%) of these awards.

CONCLUSIONS

Orthopaedic surgery had similar rates of transition to independent research funding when compared with other surgical specialties but had a lower prevalence of K awards among faculty. Orthopaedic surgeon-scientists have lower rates of transition to independent research funding when compared with their research-scientist colleagues. These findings highlight a need for greater support to foster the pipeline of future NIH-funded orthopaedic investigators.

CLINICAL RELEVANCE

As the largest support of biomedical research in the U.S., the NIH is an important stakeholder in orthopaedic innovations and discoveries. This study highlights barriers in the procurement of NIH funding across surgical specialties and affirms the need for greater resources toward supporting NIH funding in orthopaedic surgery.

Pediatric Orthopedics: Is One Fellowship Enough?

Dual-fellowship-trained surgeons specializing in both pediatric and sport medicine are treating an increasing number of pediatric orthopedic injuries, making pediatric orthopedic sports medicine a potential new emerging subspecialty. With fellowship training now being the norm rather than the exception across orthopedics, it is possible that dual-fellowship training may become a prerequisite for treatment of pediatric sports medicine patients. This may impact the practices of surgeons trained in either pediatric or sports medicine alone. As the trend toward dual-fellowship training is likely to continue, future studies are needed to characterize the impact it has on patient care and training patterns.

The Cost of Getting in: Is It Time for Change in the Adult Reconstruction Fellowship Application Process?

Background

The number of applicants to adult reconstruction fellowships (ARFs) has increased significantly in recent years, making the application process increasingly competitive. With this, applicants are applying to and interviewing at more programs which has inherent cost and time implications. The purpose of this study was to assess these implications as well as investigate applicant attitudes toward proposed changes.

Methods

This is a cross-sectional survey study of 2019 and 2020 ARF applicants (n = 278) to a single institution. A 10-question survey was distributed to applicants regarding the application and interview process. This survey focused on application and interview volumes, financial and temporal commitments, as well as perceptions regarding potential application process changes. Descriptive statistics and chi-squared analysis were then performed.

Results

Of the 110 (40%) respondents, 87% spent >$3000 and 43% spent >$5000 during the application process. Most respondents applied to ≥26 programs (84%) and both received and attended ≥11 interviews (87% and 74.5%, respectively). Applicants missed significant training time for interviews (99% missed at least 1 week, 62% two weeks, and 15% three weeks). Attending more interviews (P = .001) and multiple visits to the same city (P = .049) were associated with spending >$5000. Most applicants (72%) felt change to the process would be beneficial.

Conclusions

Applicants to ARF are applying to and interviewing at many programs resulting in significant time away from training and financial investment. Most applicants feel that a change to the system would be beneficial, although no consensus on the best solution was delineated. These data should be considered during the continued evaluation of the match process.

DPM Foot and Ankle Fellowship Selection Criteria: Survey of Fellowship Directors

BACKGROUND

A recent increase in podiatric medicine fellowships has occurred as the field continues to progress. Research regarding selection criteria from a fellowship director's perspective for potential fellows is lacking. This study aimed to examine objective and subjective selection criteria that directors consider when selecting applicants for the interview and when ranking prospective fellows after the interview.

METHODS

We electronically surveyed American College of Foot and Ankle Surgeons fellowship directors with preselected criteria for granting applicants an interview and for compiling their ranking list after the interview. A Likert scale from 1 (most important) to 5 (least important) was used to prioritize each criterion, an average rating was calculated, and the results were placed in order of importance.

RESULTS

The most important selection criteria for granting an interview were quality of residency program (1.985), a written personal statement of reasons for attending that fellowship (2.063), and publications/presentations produced as a resident (2.267). The most important criteria in completing the ranking order after the interview were assessment of applicant's personality (1.111), interview performance (1.173), and expressed interest in program (1.563).

CONCLUSIONS

Knowledge of the selection criteria that fellowship directors seek in applicants can assist those who desire to further their training. The selection criteria that program directors seek differed between being selected for the interview, which combined both objective and subjective criteria, and when compiling their rankings after the interview, which included only subjective criteria. Results show more emphasis on subjective selection criteria when directors select applicants for an interview and when ranking applicants after the interview.

Is it All About the Money? Not All Surgical Subspecialization Leads to Higher Lifetime Revenue when Compared to General Surgery

OBJECTIVE

It is believed that spending additional years gaining expertise in surgical subspecialization leads to higher lifetime revenue. Literature shows that more surgeons are pursuing fellowship training and dedicated research years; however, there are no data looking at the aggregate economic impact when training time is accounted for. It is hypothesized that there will be a discrepancy in lifetime income when delay to practice is considered.

DESIGN

Data were collected from the Medical Group Management Association's 2015 report of average annual salaries. Fixed time of practice was set at 30 years, and total adjusted revenue was calculated based on variable years spent in research and fellowship. All total revenue outcomes were compared to general surgery and calculated in US dollars.

PARTICIPANTS

The financial data on general surgeons and 9 surgical specialties (vascular, pediatric, plastic, breast, surgical oncology, cardiothoracic, thoracic primary, transplant, and trauma) were examined.

RESULTS

With fellowship and no research, breast and surgical oncology made significantly less than general surgery (-$1,561,441, -$1,704,958), with a difference in opportunity cost equivalent to approximately 4 years of work. Pediatric and cardiothoracic surgeons made significantly more than general surgeons, with an increase of opportunity cost equivalent to $5,301,985 and $3,718,632, respectively. With 1 research year, trauma surgeons ended up netting less than a general surgeon by $325,665. With 2 research years, plastic and transplant surgeons had total lifetime revenues approximately equivalent to that of a general surgeon.

CONCLUSIONS

Significant disparities exist in lifetime total revenue between surgical subspecialties and in comparison, to general surgery. Although most specialists do gross more than general surgeons, breast and surgical oncologists end up netting significantly less over their lifetime as well as trauma surgeons if they do 1 year of research. Thus, the economic advantage of completing additional training is dependent on surgical field and duration of research.