Orthopaedic surgery is consistently one of the most competitive residency fields in which to match for US senior medical students. The rationale for performing our study was to provide the incoming third- or fourth-year medical student with objective information regarding what criteria are important to match success. Specifically, we wished to delineate the role of the away rotation in match success. Doing away rotations has the potential to help an applicant in numerous ways. First, it allows applicants the opportunity to impress residents and attendings with their work ethic and ability to fit into the team. Second, it allows the student to get letters of recommendation from the orthopaedic staff at that institution, which, if written in strong support of the student, could help the student’s chance of matching not only at that school but at other programs as well. Third, it may allow the applicant to get involved in research projects or mentorship that they otherwise would not have had access to.
Strengths of our study included a representative sample of public and private medical schools in urban, suburban, and rural settings, thus providing increased external validity of our results. We were able to provide quantitative data for factors that have helped to determine match success in the past several match cycles. We have uncovered several interesting findings that may help medical students organize their fourth-year medical school schedules to provide a more comprehensive strategy to match into orthopaedic surgery and provide valuable data for mentors to use. Weaknesses include an inability to quantitatively model certain factors that certainly play a role in match success such as interviews, attending-to-attending conversations on an applicant’s behalf, and letters of recommendation [1
]. Another limitation of this study is the limited number of students studied. The variability of the study was large because the unmatched group contained only 19 students; as such, the odds ratios and confidence intervals found in the multivariate analysis are large and should be interpreted with caution. However, because the match rate of US seniors in 2007 was 80.3% and the match rate in our group was only slightly higher, we believe our sample is representative of what might be found throughout the United States. The lack of demographic data recorded for the applicants is also a limitation. This is especially true in light of the fact that the only other previous study comparing matched and unmatched students showed younger age to be a significant difference between the two groups [3
]. It is possible some of the distinction between the two groups could have been explained by demographic differences, such as age, gender, or reputation of medical school attended. These possible confounding variables are not accounted for in this study. The study also could not take into account some other factors that may play a critical role in the selection process, such as the interview day, research, letters of recommendation, personal statement, or curriculum vitae. Many of these factors may be difficult to model in a quantitative fashion, and surely other individual factors play a role in the match process. Some selection bias is likely present, because schools were selected based on their willingness to participate. Some schools would not participate because they thought the data were too sensitive, despite the fact that it was blinded to review and analysis. We did not compare match success of individual schools for two reasons. The quality of the medical school (eg, its reputation) may have no correlation to the ability of the orthopaedic department to assist their students matching. Second, owing to the number of applicants per school per year, we were unable to statistically correlate match success based on medical school attended. Likewise, we did not investigate the likelihood of a student matching at a program where they performed a rotation. There are numerous factors that may impact rotators matching at an institution at which they did a rotation or rotations. Our data were blinded to the student and, therefore, this information was not available.
Our study has numerous interesting findings. First, we found away rotations were a strong independent predictor of match success. At first, it seemed paradoxical to us on univariate analysis that students who did two away rotations would fare better than those who did three or greater. This was reconciled when we analyzed the subgroup data, which indicated students who did three or greater rotations had lower USMLE Step 1 scores, were less likely to be AOA members, and were less likely to be in the top 10% of their class. This was further clarified when our multivariate analysis showed USMLE Step 1 scores were important to match success, and the 95% confidence intervals of students who did two away rotations and those who did three or greater rotations indicated these factors were not significantly different. This suggests USMLE Step 1 score may confound the relationship an away rotation has on match success. In addition, among other factors, because Electronic Residency Application Service only allows a certain number of letters of recommendation, the marginal impact of increasing the number of away rotations may diminish after two. Therefore, it is possible, beyond two rotations, the student may only help chances of matching at the specific program where they have rotated. The home rotation is another interesting entity identified in this study. We consider this rotation to be of special significance, because it potentially could allow a student to gain increased exposure to individual attendings and residents whom they are likely to see more often than students rotating from outside institutions. This may afford them opportunities such as research and mentoring, which otherwise may not have been available to them by not being at the institution (the way an away rotator would). We considered this type of rotation separately for this reason. Bajaj and Carmichael [1
] found residency directors thought performance in an externship, class rank, and interview performance were the most important factors in match success; whereas applicants thought USMLE scores, externships, and letters of recommendation were the most important factors. Another study by Clark et al. [3
] suggested board scores and medical school grades could affect eventual match success. An analysis by Bernstein et al. [2
] suggested program directors believed performing an away rotation at the program director’s institution, USMLE Step 1 scores, and rank in medical school were the most important characteristics medical students can have. Interestingly, when asked what the most important characteristic a letter of recommendation could have, the respondents answered “the letter is written by someone I know” [2
]. This suggests a potential avenue medical students can use to their advantage when selecting away rotations and requesting letters of recommendation. In contrast to the studies by Clark et al. [3
] and Bajaj and Carmichael [1
], we found class rank and medical school grades had little effect on match success. This also could be a testimony to the strength of the applicant pool, or it could be a result of varied sampling techniques between our study and others of this type. We found USMLE scores and away rotations both are important when considered as part of the total portfolio, which confirms data from the studies by Clark et al. [3
], Bajaj and Carmichael [1
], and Bernstein et al. [2
The away rotation is an important factor in selection of candidates for residency in orthopaedic surgery. It seems apparent students who are weaker academically try to bolster their chances of match success by performing more away rotations. This is somewhat concerning because students will have 5 or more years to learn orthopaedic surgery and only the last remaining months of medical school to learn other subspecialties in medicine. In addition, our data indicate performing more than two away rotations may not improve a student’s chances of matching. That is not to say, if a student puts in a stellar performance on a third away rotation, his or her chances of matching at that institution will not improve. In general, however, it seems the third away rotation will not improve overall chances of matching. Currently in our profession, it is unclear how to optimally evaluate prospective residents. This is particularly true because of the excellent quality of applicants orthopaedic programs have received. Away rotations provide programs with a firsthand look at the affective domain of an applicant that may set them apart from other applicants. Validated metrics for future resident performance need to be defined to facilitate the resident selection process Our data do not allow us to determine what specifically helps a student match following an away rotation Additional studies are necessary to determine whether mentorship, letters of recommendation, or the actual audition is the most important factor in match success.