This Resident Roundup post comes from Mike Kim, MD, an incoming intern in the Department of Orthopaedic Surgery at the University of California, Irvine School of Medicine, and Sean Pirkle, MD, a third-year resident with the Department of Orthopaedics and Sports Medicine at the University of Washington, Seattle.
About this time 2 years ago, I (M.K.) was a rising third-year medical student with $205,000 in debt. My pre-clinical years were largely on Zoom because of COVID, and as case numbers in Los Angeles bounced up and down, I was mostly confined to my apartment. I lived a lifestyle supported only by Dave Ramsey and like-minded commentators who say Millennials can’t afford houses because they buy coffee at Starbucks. The thing is, my two largest expenses, tuition and rent, didn’t change with COVID. During these years, the lifeline that helped me stay under budget was time—time to cook, to make my own coffee, and to track my budget down to the dollar. Dave Ramsey jokes aside, this pandemic-imposed, monkish lifestyle did help me stick to my budget.
I had to readjust when I started clerkships. I had a lot less free time, and any time I did have was directed at reading, research, and maintaining a semblance of a social life and a gym routine. During clerkships, my budget lifeline was a meal credit. When you’re $250,000 in debt, $4.50 doesn’t sound like a lifeline, and I laughed the first time I heard about this perk. But soon, $4.50 per day at the county hospital cafeteria was how I afforded lunch. Even when rotating at the university hospital across the street, I’d stop by the county cafeteria on my way home to take advantage of that $4.50.
About this time 1 year ago, I was a newly minted fourth-year medical student. I now had $365,000 in debt and was applying to away rotations. It was daunting to consider how I’d manage the additional cost of travel, housing, and transportation in a new city when my budget was already stretched to the max while living in LA. I decided I wouldn’t take out any more loans to cover away rotations as I’d already maxed out my loans each of the past 3 years. Luckily, I had lifelines in 3 cities with fantastic programs where I could rotate.
Away Rotation 1 – Southeast
Travel: $602.84 / Housing: $0 / Transportation: $1,113.33
My first away rotation was in my old college town. An inflated rental car bill and $418 for mandatory fees broke my budget before I even arrived. Family friends provided a lifeline with free housing, and I made ends meet by regressing to a staple of my undergrad diet, Cookout, where $7.39 gets you a combo of 2 hotdogs, 2 corndogs, and 32 ounces of sweet tea. The lower cost of living kept my stomach full, but my arteries and pancreas paid the price.
Away Rotation 2 – Pacific Northwest
Travel: $528.90 / Housing: $972.75 / Transportation: $202.14
Two days after finishing in the Southeast, I was 2,800 miles away starting my second rotation. I was surprised by what passes for affordable housing in a city where you can sell your soul to Jeff Bezos for an attending salary straight out of undergrad. For $900 and a split of the utilities, I had a bed, a single power outlet, and a tiny bathroom shared by 6 people. I figured I didn’t need AC given the locale or a washing machine since I had scrub credits. Turns out, it was hotter than I expected, so I balled out and spent $34 on a box fan. On this rotation, my grandpa became my lifeline by letting me borrow his car for the month.
There’s no Cookout in Washington, so I leaned on my experience as a backpacking guide. I subsisted on granola, peanut butter, and beef jerky, representing all 3 essential food groups. And Celsius energy drinks. Wild Berry isn’t my favorite flavor, but Amazon sold Wild Berry 12-packs for $7 cheaper than my favorite, Tropical Vibe (thanks, Jeff). In the past, I would’ve made a budget line for Celsius, but at this point, my budget was so blown, I wasn’t really keeping track anymore. Luckily, I was at a children’s hospital, so I filled up on Cheez-Its, string cheese, and turkey sandwiches nicked from the ED pantry. Resident charity padded out the rest of my diet.
My credit card balance grew to the point where I was at risk of paying off less than the statement balance for the first time. I barely eked it out until the end of August, when my next loan was disbursed.
Rotation 3 – Southern California
Travel: $188.90 / Housing: $0 / Transportation: $125.73
My last rotation was back on home turf, a few hours’ drive south. My girlfriend lives nearby, and her family hooked me up with free housing across from the hospital. She’s always my lifeline in many ways, but she was my financial lifeline on this rotation. And since I was driving my own car, I snuck in under budget for the first time in a few months. As for food, a fellow took pity on me, and between him and the resident and getting back to the gym, I started regaining the 10 pounds I’d lost over the past couple of months.
Now, I’m a matched fourth-year medical student with $440,000 in debt. I’ve selected an income-based repayment plan and anticipate qualifying for Public Service Loan Forgiveness in 10 years. Before I sat down to write this piece, I’d already begun to forget what it felt like to biopsy my own wallet before considering where to rotate and to make the small, everyday decisions to try to stick to my meager budget. At least, it’s somewhat funny in hindsight.
I’m about as indebted as a medical student can be, but I had the choice to use loans to pay for my education. My decision not to take further loans to finance away rotations and to rotate at programs where I had lifelines were also choices. I could’ve rotated anywhere I wanted, but I was excited by the options that fit my budget. This isn’t the case for all medical students.
Away rotations are a critical, if not mandatory, part of the orthopaedic match process. They’re the best way for a program and an applicant to get a true sense of fit and significantly impact the likelihood of matching1-3. As such, away rotations are another battleground in the application arms race and a financial barrier that prevents recruiting more diverse resident classes. A study of 473 applicants in the 2019-2020 cycle who submitted data to the Texas STAR database reported a mean total cost of away rotations of $3,1824. In a 2022 survey of 650 2020-2021 applicants to the Mayo Clinic Arizona program, 27% of applicants completed 1 or 2 away rotations, 38% completed 3 away rotations, and 35% completed 4 or 5 away rotations5. Notably, these were applicants at the height of the pandemic, during which the Coalition for Physician Accountability recommended that no away rotations take place6.
The high cost of away rotations and the application process is a major barrier to improving diversity within orthopaedic surgery. While there is no easy or single solution, mitigating the cost of away rotations is a direct way for programs to address this financial barrier. At the time of this writing, only 6 programs list scholarships on the AAMC Visiting Scholars Resources Database, with others occasionally listing similar opportunities on their websites or social media7. Funding could be as modest as minimizing mandatory fees (e.g., registration, drug tests, parking) or a meal stipend. More comprehensive funding could go toward travel or housing. Many programs make statements supporting diversity on their websites and during the interview process, but few offer funding to support the applications of a diverse class. The dearth of such resources provides an opening for programs truly committed to recruiting applicants regardless of socioeconomic status to demonstrate leadership in a manner that is clear and quantifiable to applicants.
I wonder if I’m screaming into the wind. This year, there were 1.63 applicants per position8. It’s a “buyer’s market.” Don’t get me wrong, I’m not saying applying to orthopaedics shouldn’t be competitive. What I want to stress is that your bankroll should not be a selection factor, and providing funding for applicants with demonstrated need is a cost-effective improvement, even if it doesn’t solve everything. The cost of away rotations may be substantial to individual applicants, but allocating funds to defray the cost would be a rounding error to many orthopaedic departments. As an incoming intern, it’d be easier to forget about all of this and just move on with my training. However, as someone who, like many programs, has made statements about being interested in increasing diversity within orthopaedics, I’ll advocate for the changes, big or small, that push our field in the right direction. At the very least, whether it’s off my meal card or out of my own pocket, I’ll make sure my sub-interns are fed.
Residents and Trainees: Join the Orthopaedic Conversation on OrthoBuzz
Interested in being published on the JBJS OrthoBuzz blog? Residents and trainees are invited to submit a post to Resident Roundup. Share your experience as a resident, connect with others in orthopaedic training, and add your viewpoint to the orthopaedic conversation. Find out more here. Questions and submissions can be sent to orthobuzz@jbjs.org
References
- O’Donnell SW, Drolet BC, Brower JP, LaPorte D, Eberson CP. Orthopaedic Surgery Residency: Perspectives of Applicants and Program Directors on Medical Student Away Rotations. J Am Acad Orthop Surg. 2017 Jan;25(1):61-8.
- Camp CL, Sousa PL, Hanssen AD, Karam MD, Haidukewych GJ, Oakes DA, et al. The Cost of Getting Into Orthopedic Residency: Analysis of Applicant Demographics, Expenditures, and the Value of Away Rotations. J Surg Educ. 2016 Sep-Oct;73(5):886-91. Epub 20160512.
- Robin JX, Boyd CJ, Rais-Bahrami S, Ponce BA. Addressing the Financial Burdens of away Rotations in Surgical Fields. The American Surgeon™. 2022;88(7):1734-5.
- Gordon AM, Malik AT, Scharschmidt TJ, Goyal KS. 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 Jan-Mar;6(1). Epub 20210317.
- Rosenow CS, Brinkman JC, Deckey DG, Tummala SV, Pollock JR, Spangehl MJ, et al. Orthopaedic Surgery Away Rotations: Current Issues and Lessons Learned. JBJS Open Access. 2022 Apr-Jun;7(2). Epub 20220425.
- Group CfPAW. Final report and recommendations for Medical Education Institutions of LCME-accredited, US osteopathic, and non-US medical school applicants. 2020.
- Exploring the Visiting Scholars Resources Database [database on the Internet]. Association of American Medical Colleges. 2024 [cited 4/9/24]. Available from: https://students-residents.aamc.org/students/exploring-visiting-scholars-resources-database.
- Advance Data Tables: 2024 Main Residency Match [database on the Internet]. National Resident Matching Program. 2024 [cited 04/16/2024]. Available from: https://www.nrmp.org/wp-content/uploads/2024/03/Advance-Data-Tables-2024.pdf.