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Orthopedic Surgery Competitiveness: Matching, Clerkships, USMLE Scores, 4th Year, Subinternships & More

Matching into an ultra-competitive specialty like orthopedic surgery requires significant dedication, confidence, and a stellar application to back you up. For most, this is an uphill task. Per the AAOS, there are now 154 accredited orthopedic residency programs, 640 positions available for new residency applicants, and approximately 1.15 applicants for each position. So, what makes you a competitive applicant?

What Makes a Competitive Orthopedic Surgery Applicant

According to NRMP’s Charting Outcomes in the Matchmatched applicants averaged 12.5 programs ranked, a USMLE Step 1 score of 248, and a USMLE Step 2 CK score of 255. Conversely, unmatched applicants averaged 6.6 programs ranked, a Step 1 score of 240, and a Step 2 CK score of 246.

Amazingly, the number of research experiences, publications, presentations, work experiences, and volunteer experiences did not significantly impact a prospective resident’s chance at matching, as long as the prospective resident had at least one experience in each category. AOA status may improve the applicant’s chance of a successful match (more than 40% of matched applicants were elected members of AOA), but does not guarantee matching (nearly 16% of unmatched applicants were elected to AOA). Clearly, the discrepancy in matched vs. unmatched lies in the number of programs who have invited you for an interview, a high Step 1 score, a high Step 2 CK score and at least one form of research and volunteer experience that can be meaningfully discussed at an interview.

Which brings us to the USMLE Step 1. Clearly, your Step 1 score matters. Many programs will never even review the applications from students scoring below a certain threshold on Step 1 (often times < 230). Thus, the best thing you can do to improve your chances of a successful match is to work hard during your first two years to achieve a high score on the USMLE.

However, if your Step 1 score is less than ideal, don’t give up. There are still opportunities to impress program directors through your Step 2 CK scores, evaluations, and away rotations. 

Third Year Clinical Rotations

If you know that you want to be an orthopedic surgeon, you don’t have to hide it in your third year rotations! In fact, the converse may help you to approach each rotation with an open mind! Third year clinical rotations will not only prime you for your fourth year away rotation auditions, but also teach you how to care for the entire patient, not just his/her orthopedic problem.

You should work with your attendings and residents to make the rotation as applicable to you as possible. For example, while on Internal Medicine, you may be asked to care for an elderly patient with a complicated medical history of CHF, ESRD, and Alzheimer’s Dementia, admitted to the hospital for operative fixation of an intertrochanteric (hip) fracture.

Although you may not be explicitly caring for patients with medical problems or OB/GYN problems as an orthopedic surgeon, you will be asked to treat and care for patients who have these problems. It is in your best interest to have an open mind and show interest in all of your rotations – this is likely the only non-orthopedic clinical education you’ll get in your career.

(For more tips on clerkship success, check out my post on how to excel in clinical rotations.)

How to Schedule Your 4th Year Rotations if You Plan on an Orthopedic Surgery Residency

If you desire a residency in orthopedic surgery, you should time your USMLE Step 2 CK to maximize the potential of your application. If your Step 1 score is above the average matched (245), then you can delay Step 2 CK until after applications are due. If your Step 1 score is below average, you should take the examination immediately after third year. A great Step 2 CK score can mask a below average Step 1 score; however, poorer performance on Step 2 CK can detract from a high score on Step 1.

After you’ve decided on the timing of Step 2 CK, you should look to schedule 1 subinternship in orthopedic surgery at your home program and 2-3 subinternships at other institutions through the VSAS application service.

Subinternships afford you the opportunity to learn orthopedics clinically and be exposed first hand to the profession you love. You’ll want to use the subinternship to identify the type of program you want to rank higher (operative heavy, research heavy, trauma heavy, or balanced), as well as to ask for strong letters of recommendation from well known attendings you work with. Anyone can get a strong letter of recommendation from their home program’s Department Chair, so your application will be much stronger if you have three well known attendings from three different institutions write letters in support of your application.

However, it is imperative that your first subinternship is at your home institution. The attendings and residents at your home program are on your side. They want you to succeed, and they want you to carry their strong reputation to programs you visit, both for away rotations and interviews. They expect that you know nothing about orthopedic surgery aside from musculoskeletal anatomy and basic surgical approaches.

After that, your job is simple. Be the first member of your team to the hospital, collect and interpret vital signs and labs in a relevant fashion in relation to their clinical and surgical history, prepare your patients for morning rounds (this includes having dressing change materials at the ready), know your patients prior to surgery, follow all patients you operated on (yes, you read that correctly), be efficient in clinic, and be a person we want to hang out with on a 30-40 hour call for the next 5 or 6 years.

Once on away rotations, the residents and attendings have nothing invested in your success. Yes, they want you to succeed, but they will not go out of their way, like your home program, to ensure your success. Because of this, it is imperative to be well-seasoned with your home program’s orthopedic surgery subinternship prior to going on away rotations.

How To Prepare for a Subinternship in Orthopedic Surgery

Some books that may help you to master orthopedic knowledge during your orthopedic surgery subinternship are:

I recommend that you read Netter’s Concise Orthopaedic Anatomy prior to your first subinternship. You can keep the Handbook of Fractures, Surgical Exposure in Orthopaedics, and Essential Anatomy 5 in your back pocket for easy reference during rotations.

Keep in mind, the subinternship is analogous to a month long interview. It is one month to prove that you deserve a highly selective spot in their highly selective residency program. Remember, the most important part of your subinternship is to have fun. Orthopedics is a phenomenal specialty (I would argue the best), and if you keep yourself competitive and excited, the subinternship is the beginning of the rest of your career. 

What should I expect during match week?

On the Monday of match week at 11:00AM ET, you will find out if you matched. A career defining email from the NRMP will arrive in your inbox with the ominous subject line, “Did I Match?” Three words that define the next stage of your training. For roughly 70% of prospective orthopedic residents, a soothing “Congratulations, you have matched!” waits on the other side of the email. Four days later, on the Friday of match week, you will open your envelope with every other medical student in the country at 12:00pm ET to find out where you matched. After Match, take time to enjoy the rest of your fourth year vacation. Residency starts July 1.

Match week is the most anxiety provoking, nauseating, frustrating, sleepless, and gratifying week of medical school. I spent the final four weeks leading up to Match Day with limited sleep perpetuating my every growing anxiety and binge eating of greasy, salty, and sugary foods. I constantly perseverated over “Will I match? Where will I match? What if my fiancé doesn’t want to go where I matched? What if I don’t want to go where I matched?” But on Monday, March 14, 2016, I learned that I matched, and the only thing that mattered was that I matched, and I was going to be an orthopedic surgeon. On Friday, March 18, 2016, I learned I would be completing my training at the University of North Carolina Chapel Hill. I couldn’t be happier. I couldn’t be more excited. And I never had a more restful night’s sleep in my life.