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The COVID-19 Pandemic Increased the Use of Virtual Fellowship Interviews, Reduced Case Volume, and Limited Sideline Coverage Opportunities During Sports Medicine Surgeon Training

Open AccessPublished:March 16, 2023DOI:https://doi.org/10.1016/j.asmr.2023.02.015
The COVID-19 Pandemic Increased the Use of Virtual Fellowship Interviews, Reduced Case Volume, and Limited Sideline Coverage Opportunities During Sports Medicine Surgeon Training
Previous ArticleHigh Return to Play Rate and Diminished Career Longevity are Seen Following Arthroscopic Shoulder Labral Repair in Major League Baseball Players

      Abstract

      As one-year orthopaedic sports medicine fellowships rely heavily on elective cases and sports coverage, the COVID-19 pandemic necessitated fellowship programs to temporarily transition to virtual mediums for fellow education. Early in the pandemic, there was uncertainty as to how programs would address concerns of trainee readiness, adequate education, and accompanying psychological impact. However, with a return to prepandemic elective procedure volumes and sideline sports coverage responsibilities, sports medicine fellowships have regained some of their traditional education opportunities. Moreover, the implementation of novel training resources, including virtual didactics, augmented reality surgical skills labs, and telehealth medicine training are poised to outlast the current public health crisis and further supplement fellowship education. This article seeks to report on current evidence-based strategies and developments across several critical aspects of sports medicine training during the COVID-19 pandemic.

      Introduction

      The COVID-19 pandemic has led to a dramatic reevaluation and adjustment to maintain the highest standards of physician training across medical specialties. As one-year orthopaedic sports medicine fellowships heavily rely on elective cases, programs were relegated to integrating virtual means of fellow education. While programs with necessary resources have been able to effectively incorporate alternative modes of education, a recent survey reported that a majority of the sports medicine fellowship class of 2020 agreed that their education was negatively affected, had doubts of readiness, and experienced increased stress and anxiety related to future professional endeavors.
      • Perrone M.A.
      • Youssefzadeh K.
      • Serrano B.
      • Limpisvasti O.
      • Banffy M.
      The impact of COVID-19 on the sports medicine fellowship class of 2020.
      Orthop J Sports Med. 2020; 82325967120939901
      However, as the COVID-19 pandemic continues to evolve along with the return of normal case volume, the implementation of previously underutilized resources, including virtual didactics, augmented reality surgical skills labs, and greater utilization of telehealth medicine will serve to further supplement and improve fellow education (Table 1).
      • Stambough J.B.
      • Curtin B.M.
      • Gililland J.M.
      • et al.
      The past, present, and future of orthopedic education: Lessons learned from the COVID-19 pandemic.
      J Arthroplasty. 2020; 35: S60-S64
      ,
      • Plancher K.D.
      • Shanmugam J.P.
      • Petterson S.C.
      The changing face of orthopaedic education: Searching for the new reality after COVID-19.
      Arthrosc Sports Med Rehabil. 2020; 2: e295-e298
      Although it is unclear how the COVID-19 pandemic will affect sports medicine fellowship training within the next 3-5 years, these novel training approaches will likely continue to be incorporated into curriculums moving forward. This article seeks to report on current evidence-based strategies and developments across several critical aspects of orthopaedic sports medicine training.
      Table 1Orthopaedic Sports Medicine Fellowship Training Opportunities Affected by the COVID-19 Pandemic and Strategies Implemented by Program Directors to Minimize the Disruptions
      Aspects of Training Affected by COVID-19 PandemicStrategies to Minimize Training Disruption
      Loss of in-person fellowship interviews and visits

      Missed opportunities to assess “fit” for applicants and program      		Virtual interviews conducted via web-based conferencing platforms

      Online social events and facility video tours
      Cancellation of elective orthopaedic surgical procedures

      Considerably decreased fellow case volume and operating time      		Web-based fellowship and industry-sponsored didactics

      Online journal clubs

      Virtual reality surgical skills lab training
      Sideline sports coverage opportunities from the high school to professional level

      Interactions with players, coaches, and agents      		Team physician-led case discussions

      Fellow sideline telemedicine training for

      injury evaluations and potential consults with

      athletes and trainers
      Postponed traveling fellowships and leadership development initiatives for practicing orthopaedic sports medicine physiciansAccepted fellows allowed to participate in traveling fellowships the following year

      Online leadership lectures and forums

      Changing Landscape of the Orthopaedic Sports Medicine Fellowship Interview

      During the 2020-2021 and 2021-2022 fellowship interview cycles, orthopaedic sports medicine fellowship interviews were conducted virtually through various platforms. Although the future of fellowship interviews remains unclear, there has been considerable debate weighing the pros and cons of continuing to conduct interviews in this nontraditional manner during subsequent interview cycles.
      • Kraeutler M.J.
      An applicant's review of virtual fellowship interviews: The new norm?.
      Arthroscopy. 2021; 37: 1704-1705
      Historically, fellowship interviews were held in-person at the respective program site and varied from half-day to full-day interview schedules.
      • Haislup B.D.
      • Kraeutler M.J.
      • Baweja R.
      • McCarty E.C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship interviews: Structure and organization of the interview day.
      Orthop J Sports Med. 2017; 52325967117741276
      However, along with an estimated 90-95% of orthopaedic surgery residents pursuing fellowship positions, increasing concerns have been raised regarding the financial and educational impact of attending in-person interviews.
      • Gordon A.M.
      • Malik A.T.
      • Scharschmidt T.J.
      • Goyal K.S.
      Cost analysis of medical students applying to orthopaedic surgery residency: Implications for the 2020 to 2021 application cycle during COVID-19.
      JB JS Open Access. 2021; 6 (00158): e20
      , 
      • Taylor A.J.
      • Sobel A.D.
      • Mulcahey M.K.
      Perceptions of the educational and institutional impact of the orthopaedic fellowship interview process.
      J Am Acad Orthop Surg. 2020; 28: e948-e953
      , 
      • Mulcahey M.K.
      • Hayes M.K.
      • Smith C.M.
      • Kraeutler M.J.
      • Trojan J.D.
      • et al.
      Outcomes in the orthopaedic sports medicine fellowship match, 2010-2017.
      Orthop J Sports Med. 2018; 62325967118771845
      On the financial side, the overall cost per applicant of in-person interview-related expenses is estimated to be $5,875 per interview season.
      • Oladeji L.O.
      • Pehler S.F.
      • Raley J.A.
      • Khoury J.G.
      • Ponce B.A.
      Is the orthopedic fellowship interview process broken? A survey of program directors and residents.
      Am J Orthop (Belle Mead NJ). 2015; 44: E444-E453
      ,
      • Swarup I.
      • Luhmann S.
      • Woiczik M.
      • Sankar W.N.
      Eight years of the pediatric orthopaedic fellowship match: What have we learned?.
      J Pediatr Orthop. 2020; 40: e144-e148
      In addition to the time and cost it takes to travel to on-site interviews, previous studies demonstrated concern among 62% of program directors regarding the time away from medical training and its impact on hospital workflow.
      • Taylor A.J.
      • Sobel A.D.
      • Mulcahey M.K.
      Perceptions of the educational and institutional impact of the orthopaedic fellowship interview process.
      J Am Acad Orthop Surg. 2020; 28: e948-e953
      ,
      • Oladeji L.O.
      • Pehler S.F.
      • Raley J.A.
      • Khoury J.G.
      • Ponce B.A.
      Is the orthopedic fellowship interview process broken? A survey of program directors and residents.
      Am J Orthop (Belle Mead NJ). 2015; 44: E444-E453
      The past two fellowship interview cycles have further magnified these concerns, as virtual interviews demonstrated greater than $5,000 in savings for applicants and over $2,500 in savings for programs.
      • Clark S.C.
      • Kraeutler M.J.
      • McCarty E.C.
      • Mulcahey M.K.
      Virtual interviews for sports medicine fellowship positions save time and money but don't replace in-person meetings.
      Arthrosc Sports Med Rehabil. 2022; 4: e607-e615
      Further advantages for fellowship programs were highlighted by a survey following the 2020-2021 application cycle, including a greater number of interview days offered (18% of programs), more interviewees per interview (53%), and a greater ability for applicants to attend more interviews (80%).
      • Clark S.C.
      • Kraeutler M.J.
      • McCarty E.C.
      • Mulcahey M.K.
      Virtual interviews for sports medicine fellowship positions save time and money but don't replace in-person meetings.
      Arthrosc Sports Med Rehabil. 2022; 4: e607-e615
      Conversely, 58% of program directors (PDs) agreed/strongly agreed that virtual interviews negatively impacted a personal connection with applicants, compared to 43% of applicants who agreed/strongly agreed that virtual interviews negatively affected their personal connection to the program.
      • Clark S.C.
      • Kraeutler M.J.
      • McCarty E.C.
      • Mulcahey M.K.
      Virtual interviews for sports medicine fellowship positions save time and money but don't replace in-person meetings.
      Arthrosc Sports Med Rehabil. 2022; 4: e607-e615
      Ultimately, the 2020-2021 application cycle led to a 92% match rate and 93% of orthopaedic sports medicine fellowship positions filled, with only 29% of respondents reporting that virtual interviews negatively affected their ability to match at their desired program. Overall, concurrent with other orthopaedic subspecialty surveys, PDs and applicants favored virtual interviews, which suggests that virtual interviews may continue to play a role in future application cycles.
      • Healy W.L.
      • Bedair H.
      Videoconference interviews for an adult reconstruction fellowship: Lessons learned.
      J Bone Joint Surg Am. 2017; 99: e114
      However, it has been suggested that virtual interviews should improve on providing a better overview of the program facilities, educational opportunities, more interaction with faculty and current fellows, and strategies to improve avenues for personal connections between the applicants and programs.
      • Peebles L.A.
      • Kraeutler M.J.
      • Waterman B.R.
      • Sherman S.L.
      • Mulcahey M.K.
      The impact of COVID-19 on the orthopaedic sports medicine fellowship application process.
      Arthrosc Sports Med Rehabil. 2021; 3: e1237-e1241
      To address these issues, it has been proposed that PDs may consider hybrid interviews where applicants are offered the option of either a virtual or in-person interview, or alternatively for PDs to perform interviews at a neutral site (such as the American Academy of Orthopaedic Surgeons [AAOS] Annual Meeting), which allows applicants to hold in-person interviews with all prospective programs.
      • Peebles L.A.
      • Kraeutler M.J.
      • Waterman B.R.
      • Sherman S.L.
      • Mulcahey M.K.
      The impact of COVID-19 on the orthopaedic sports medicine fellowship application process.
      Arthrosc Sports Med Rehabil. 2021; 3: e1237-e1241
      Orthopaedic sports medicine fellowships remain highly competitive. Prior to the COVID-19 pandemic, a survey of 57 fellowship PDs found that the most important criteria for a successful match for both programs and applicants included quality of the interview, letter of recommendations, the strength of the applicant’s residency program, research experience, and personal connections.
      • Baweja R.
      • Kraeutler M.J.
      • Mulcahey M.K.
      • McCarty E.C.
      Determining the most important factors involved in ranking orthopaedic sports medicine fellowship applicants.
      Orthop J Sports Med. 2017; 52325967117736726
      ,
      • Grabowski G.
      • Walker J.W.
      Orthopaedic fellowship selection criteria: A survey of fellowship directors.
      J Bone Joint Surg Am. 2013; 95: e154
      In the current state of virtual interviews, it has been suggested that the greatest detriment to virtual interviews is the reciprocal lack of a quality holistic assessment, potentially leading to decreased confidence in assessing one’s “fit” for a particular program.
      • Kraeutler M.J.
      An applicant's review of virtual fellowship interviews: The new norm?.
      Arthroscopy. 2021; 37: 1704-1705
      As a result, relationships, research productivity, strength of letters of recommendation, and residency program reputation may carry more weight than the quality of the interview for PDs for future application cycles.
      • Peebles L.A.
      • Kraeutler M.J.
      • Waterman B.R.
      • Sherman S.L.
      • Mulcahey M.K.
      The impact of COVID-19 on the orthopaedic sports medicine fellowship application process.
      Arthrosc Sports Med Rehabil. 2021; 3: e1237-e1241
      The practice of “pipelining” at top fellowship programs may further worsen the chances for certain qualified applicants from residency programs without an established reputation, as these applicants are unable to “prove themselves” during an in-person interview.
      • Tanguilig G.
      • Kraeutler M.J.
      • Mulcahey M.K.
      The top 10 orthopaedic sports medicine fellowship programs in the United States frequently select fellow applicants from the same residency programs.
      Arthrosc Sports Med Rehabil. 2023; 5: e411-e414
      Ultimately, future surveys and longitudinal investigations are needed to determine whether the current perceptions of virtual interviews hold up over time, and whether return to traditional or alternative interview processes are necessary.

      Impact of COVID-19 on Sports Medicine Fellow Operating Experience and Case Volume

      In the wake of the COVID-19 pandemic, greater attention has been given to its potential short- and long-term effects on postgraduate medical and surgical training. In March 2020, the US Surgeon General recommended a delay of all elective and nonessential medical and surgical procedures to reduce disease transmission and conserve medical supplies and personal protective equipment to treat the critically ill. Shortly after that, the American College of Surgeons and American Academy of Orthopaedic Surgeons published recommendations for optimal management and triage of elective, nonemergent surgical procedures.
      American College of Surgeons
      COVID-19: Recommendations for management of elective surgical procedures.
      https://www.facs.org/for-medical-professionals/covid-19/clinical-guidance/elective-surgery/
      Date accessed: February 26, 2023
      ,
      • Guy D.K.
      • Bosco III, J.A.
      • Savoie III, F.X.
      AAOS guidelines for elective surgery during the COVID-19 pandemic.
      https://www.aaos.org/about/covid-19-information-for-our-members/aaos-guidelines-for-elective-surgery/
      Date accessed: February 26, 2023
      In orthopaedic sports medicine, a specialty in which most surgical procedures are considered elective, these new guidelines had considerable effects on the case volume of fellows who rely on repetitive surgical exposure in their final year of preparation for independent practice.
      • Guy D.K.
      • Bosco III, J.A.
      • Savoie III, F.X.
      AAOS guidelines for elective surgery during the COVID-19 pandemic.
      https://www.aaos.org/about/covid-19-information-for-our-members/aaos-guidelines-for-elective-surgery/
      Date accessed: February 26, 2023
      ,
      • Reider B.
      Sports medicine in a time of pandemic.
      Am J Sports Med. 2020; 48: 1303-1304
      Because of the recent and ongoing nature of the COVID-19 pandemic, few studies have been able to provide quantitative data regarding the true impact of the pandemic on the case volume of orthopaedic sports medicine fellows. In a survey of 101 orthopaedic sports medicine fellows conducted in April 2020, nearly all (98/101, 97.0%) reported that their fellowship programs enacted policies to limit case or clinic volumes, with 72.3% reporting implementation between March 11 and March 20, 2020.
      • Perrone M.A.
      • Youssefzadeh K.
      • Serrano B.
      • Limpisvasti O.
      • Banffy M.
      The impact of COVID-19 on the sports medicine fellowship class of 2020.
      Orthop J Sports Med. 2020; 82325967120939901
      Although only 19.8% of fellows experienced a complete suspension of surgical procedures, 76.2% reported they were still assisting in urgent or emergent cases. Most (47.5%) sports medicine fellows had a typical weekly caseload of 11 to 15 cases prior to the COVID-19 pandemic; however, over 90% reported having performed fewer than 20 cases since implementing restrictions on performing elective procedures to the time of the survey in April 2020. Considering these drastic decreases in case volumes, programs have widely embraced web-based educational experiences in the form of fellowship- or industry-sponsored didactics and remote journal clubs, and some even offered fellowship extensions to the 2019-2020 class.
      • Perrone M.A.
      • Youssefzadeh K.
      • Serrano B.
      • Limpisvasti O.
      • Banffy M.
      The impact of COVID-19 on the sports medicine fellowship class of 2020.
      Orthop J Sports Med. 2020; 82325967120939901
      Remote journal clubs allow fellows to engage in discussions with faculty across the world on the most recent advancements in the field of orthopaedic surgery, increase their exposure to novel surgical techniques, and instill career-long habits of staying up-to-date on orthopaedic literature.
      • Campbell S.T.
      • Kang J.R.
      • Bishop J.A.
      What makes journal club effective? A survey of orthopaedic residents and faculty.
      J Surg Educ. 2018; 75: 722-729
      Although it is impossible to recreate operative experiences in a remote setting, industry-sponsored didactics may allow fellows to engage with expert speakers and learn more about medical devices available to them in their operating rooms when starting practice.
      In a 2022 study conducted by Heaps et al.,
      • Heaps B.M.
      • Dugas J.R.
      • Limpisvasti O.
      The impact of COVID-19 on orthopedic surgery fellowship training: A survey of fellowship program directors.
      HSS J. 2022; 18: 105-109
      190 PDs of accredited orthopaedic surgery fellowships across the United States were surveyed in October 2020 regarding their perceptions of how the COVID-19 pandemic impacted the education of the 2019-2020 fellowship class and its potential effects on programs in the future. Although this decrease in surgical case volume and in-person educational experiences appeared daunting at first, it was reported that most fellowship PDs believed that there would be no negative impact on the level of patient care provided by fellows once they entered practice over the next 3 to 5 years.
      • Heaps B.M.
      • Dugas J.R.
      • Limpisvasti O.
      The impact of COVID-19 on orthopedic surgery fellowship training: A survey of fellowship program directors.
      HSS J. 2022; 18: 105-109
      Another encouraging finding identified in this study was that 86% of PDs reported learning new ways to educate fellows, and 68.3% felt that their fellows were better trained in virtual medicine and telehealth consultations because of these pandemic-related educational changes. As the volume of elective procedures begins to return to prepandemic levels, future studies should aim to report on which supplemental educational opportunities continue as a mainstay in orthopaedic sports medicine fellowship training and the rate of return to prepandemic fellow case volumes.

      Sideline Coverage During the COVID-19 Pandemic

      It is also important to consider how lost opportunities outside of the operating room due to COVID-19 may negatively impact sports medicine fellowship training. One of the unique experiences of sports medicine coverage is the opportunity to interact and care for athletes at all skill levels. Learning how to effectively care for these athletes and develop relationships with their coaches, athletic trainers, and families is a crucial skill set that is further developed during this period of a fellow’s training.
      • Peebles L.A.
      • Aman Z.S.
      • Kraeutler M.J.
      • Mulcahey M.K.
      Impact of the COVID-19 pandemic on sports medicine patient care.
      Arthroscopy. 2023; 39: 161-165
      However, after the widespread cancellation of organized sporting events in spring 2020 across the high school to professional levels, fellows lost the opportunity to hone such skills that are impossible to obtain through observation and remote learning.
      • Liles J.L.
      • Danilkowicz R.
      • Dugas J.R.
      • et al.
      In response to COVID-19: Current trends in orthopaedic surgery sports medicine fellowships.
      Orthop J Sports Med. 2021; 92325967120987004
      In a 2021 survey of 90 sports medicine fellows in the United States and Canada, nearly half identified these missed sports coverage opportunities as the greatest loss to their fellowship education.
      • Stein C.J.
      • Buller R.I.
      • Kivlehan E.J.
      • et al.
      Fellows' perspective of educational changes in medical sports medicine during the COVID-19 pandemic.
      Cureus. 2022; 14e26199
      In the same survey, 100% of respondents indicated that they had abundant or adequate exposure to sports coverage prior to the pandemic, but only 7.7% responded similarly following the implementation of COVID-19 restrictions. With athletes returning to full participation for their respective seasons with limited nonessential personnel, it is critical that sports medicine fellowship program directors definitively address these changes in training to limit their impact on the future careers of their fellows.

      Traveling Fellowship Opportunities

      Orthopaedic surgery traveling fellowships are designed to foster leadership development among early-career surgeons by providing opportunities for academic, clinical, and cultural exchange. Over the course of these fellowships, surgeons visit multiple domestic and international sites to network with regional orthopaedic experts, observe in the operating room, interact with patients, and engage in scientific endeavors and case discussions. Traveling fellowships have been shown to substantially impact future career trajectory, with graduating fellows frequently receiving research grant funding, prestigious academic appointments, and high-ranking society leadership positions.
      • Simon M.A.
      • Stautzenbach T.E.
      Leaders are made, not born. The role of the American Orthopaedic Association leadership traveling fellowships and leadership development programs.
      J Bone Joint Surg Am. 2003; 85: 1833-1836
      The importance of such programs becomes even more apparent when considering the limited scope of leadership development opportunities available for young surgeons in the early phases of their careers.
      • Yayac M.
      • Trojan J.D.
      • Brown S.
      • Mulcahey M.K.
      Formal leadership training for orthopedic surgeons: Limited opportunities amongst growing demand.
      Orthop Rev (Pavia). 2019; 11: 8151
      ,
      • D'Ambrosi R.
      • Vaishya R.
      The importance of travel fellowships in orthopaedic surgery: Return to normality after COVID pandemic.
      J Orthop. 2022; 32: A1-A2
      In the wake of the COVID-19 pandemic, some of the most prestigious traveling fellowships were either cancelled or delayed for the 2020-2021 cycle, including those organized by the American Orthopaedic Society for Sports Medicine (AOSSM), the American Orthopaedic Association (AOA), and the Arthroscopy Association of North America (AANA). Although many of the accepted traveling fellows were able to participate in these programs the following year, and these changes are largely limited to the 2020-2021 fellowship class, this resulted in a delay of training at a particularly tumultuous time in the careers of these young orthopaedic surgeons. Future reports may consider discussing the implications of these delays in surgeon training and their effects on the availability of positions for subsequent years. It is important to acknowledge the limitations of this article in that the impacts of COVID-19 have begun to normalize, as fellow case volumes and traveling fellowship opportunities return to their prepandemic levels. Although sideline sports medicine coverage has been reinstated at the high school and collegiate levels, on-field professional team coverage opportunities remain severely limited for some current fellows when compared to those available prior to COVID-19.

      Conclusion

      Although the COVID-19 pandemic presented novel challenges in the training of orthopaedic sports medicine surgeons, fellows and program directors have adapted and established new standards of medical education that are positioned to outlast the current public health crisis. Sports medicine fellowship interviews were conducted exclusively remotely for 2 cycles following the beginning of the pandemic and programs have widely embraced web-based didactics to supplement fellow education. Sports medicine fellows experienced a drastic decrease in total case volume, as well as opportunities for sideline team sports coverage. The cancellation of traveling fellowships also severely limited the number of available opportunities for professional leadership development that are crucial for newly practicing orthopaedic sports medicine surgeons.

      Supplementary Data

      References

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        The impact of COVID-19 on the sports medicine fellowship class of 2020.
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        What makes journal club effective? A survey of orthopaedic residents and faculty.
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      Article info

      Publication history

      Published online: March 16, 2023
      Accepted: February 28, 2023
      Received: December 18, 2022

      Publication stage

      In Press Corrected Proof

      Footnotes

      The authors report the following potential conflicts of interest or sources of funding: M.K.M. reports being a board or committee member of AAOS, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Ruth Jackson Orthopaedic Society, and The Forum; editorial or governing board membership in American Journal of Sports Medicine Electronic Media, Arthroscopy, Ortho Info; speaker fees from Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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      DOI: https://doi.org/10.1016/j.asmr.2023.02.015

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      © 2023 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.

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