Introduction
Female physicians have been historically underrepresented in orthopaedic surgery residencies in the United States and the percentage of women in orthopaedic surgery continues to be among the lowest of all fields of medicine1. There is a paucity of literature investigating the distribution of female physicians among orthopaedic surgery residencies. Over the past 10 years, the number of female orthopaedic surgeons has increased at a rate of only 2% per year2. This disparity continues although women make up over half of total matriculating US medical students (53% as of the 2019-2020 cycle, according to the American Medical Association [AMA]). Orthopaedic surgery residency programs select students based on factors such as performance on orthopaedic surgery rotations, letters of recommendation, US Medical Licensing Examination (USMLE) scores, and interview performance, while applicants rank programs based on location, reputation, and resident lifestyle. Previous studies have explored factors that motivate or dissuade women from pursuing careers in orthopaedic surgery, but data investigating the distribution of female physicians among orthopaedic surgery residencies and how this affects female matriculants into programs in the United States are limited.
In 2016, O'Conner found that female applicants are more likely than male applicants to discount programs based on sex biases such as illegal questions during residency interviews and that female applicants are more likely to receive such questioning. In addition, O'Conner suggested that female applicants may be more likely to apply to fields in which they have female role models and early exposure during medical school3. Lack of strong mentorship has been cited as a common reason for not pursuing orthopaedic surgery4. In 2018, Sobel et al. explored factors that influenced sex diversity in orthopaedic surgery residency programs by assessing the total number of female residents and faculty, programs that had a dedicated women's sports medicine program, and had 4 defined maternity leave policies5. The authors found that there were higher percentages of female residents at orthopaedic surgery residency programs with more female faculty members, more women in leadership positions, a women's sports medicine program, and the option to do a research year5. The purpose of this study was to determine whether sex diversity among orthopaedic residency programs and faculty is associated with an increased number of female applicants matriculating into that program. In addition, we sought to analyze female resident matriculation trends over the past 5 years as a follow-up to the 2018 study by Sobel et al.
Methods
The AMA Fellowship and Residency Electronic Interactive Database was used to identify all allopathic orthopaedic surgery residency programs during the 2021 to 2022 academic year in the United States. Data for this study consisted of intern, resident, and faculty demographic characteristics and were collected from residency programs and hospital websites, social media, and direct contact with programs when data could not be found online.
Intern, resident, and faculty demographic data included the total number of interns, residents, and faculty members as well as the female complement of each; the number of full female professors, associate professors, residency program/associate program directors, section chiefs, and female faculty in leadership positions; the presence of a female chairperson; and the presence of a women's sports medicine program. A women's sports medicine program is a formal organization that is dedicated specifically to the treatment of active women and is typically associated with a department of orthopaedic surgery. Data for female leadership positions included section chiefs, program/associate program residency directors, fellowship program directors, chair or vice chair positions, and any other leadership distinction cited through the program's website. The sex of each resident and faculty member was determined using photographs and names cited by the program's website and through cited pronouns when available. As such, we were limited in our ability to document individuals who identify as nonbinary.
The average number of residents per intern year and the average number of female interns per orthopaedic surgery residency program in the United States during the 2021 to 2022 academic year were calculated. These values are reported as means with the SD of the data. The percentages of female residents, number of female residents, female faculty, full professors, female associate professors, female section chiefs, female resident program/associate program directors, and the total number of women in leadership positions were compared with the 2018 study data, which included data from the 2016 to 2017 academic year5.
Programs were stratified based on the percentage of female residents and female interns. Quartiles of programs based on the percentage of female residents and female interns were determined, and to highlight programs that have the highest percentages of female residents and female interns, the programs in the top (fourth) quartile were selected. Data were then compared between the top quartile and the other (combined first through third) quartiles. Continuous data were analyzed with independent t tests. For all statistical tests, significance was set at p < 0.05.
Source of Funding
There was no funding for this investigation, and funding source did not play a role in the investigation.
Results
Data were obtained from 144 of 146 (98.6%) allopathic, nonmilitary, orthopaedic surgery residency programs in the United States. Two programs were excluded because of a lack of useable data on their websites and a lack of response to emails sent to the programs to obtain resident and faculty information. A total of 696 female residents (19.2%) were identified from a total of 3,624 orthopaedic residents. In addition, a total of 160 female interns (22.1%) were identified out of a pool of 723 interns total in orthopaedic programs. Fourteen programs (9.6%) had no female women residents, and 54 (37.5%) had no female interns. Programs were divided into top vs. other quartile programs based on the percentage of female residents, and programs were plotted on a box plot (Figs. 1 and 2). The top quartile of programs had a 25% complement of female residents, and no program had more than 40% female residents. When comparing the number of women residents in orthopaedic residencies in the past five years, there was a significant increase in the average number of women residents per program. (4.8 ± 3.85 vs. 3.33 ± 2.67, p < 0.001). Additionally, the threshold for top-quartile programs based on the percentage of women residents increased from 20% to 25% over the five years. The number of programs in 2022 that would have fit into the top quartile in 2017 is 53 compared with the 35 included in 2016 to 2017 (p = 0.03).
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Fig. 1: Distribution of Programs by Percentage of Female Residents. Box plot showing the 25th and 75th quartiles (top and bottom of the box), mean (x), and median (central line) of the distribution of orthopaedic surgery residency programs in the United States based on their percentage of female residents. The whiskers indicate the minimum value of the first quartile and the maximum value of the fourth quartile, excluding any outliers.
Fig. 2: Distribution of Programs by Percentage of Female Interns. Box plot showing the 25th and 75th quartiles (top and bottom of the box), mean (x), and median (central line) of the distribution of orthopaedic surgery residency programs in the United States based on their percentage of female interns. The whiskers indicate the minimum value of the first quartile and the maximum value of the fourth quartile, excluding any outliers.
There was no significant difference in the mean number of total faculty per program (43.30 [SD 34.49] vs. 33.77 [SD 20.99], p = 0.06). Programs in the top quartile of female faculty had a mean of 6 female faculty members (18.3% of all faculty). Eight programs (5.5%) had no female faculty. Programs in the top quartile of female residents had a significantly greater number of female faculty per program than the lower quartiles (5.76 [SD 4.68] vs. 4.18 [SD 3.80], p = 0.049).
Most programs that had over 18.3% of female faculty were in the top quartile of female residents and female interns. Programs in the top quartile of female residents had 3 times the number of female residents per program when compared to other quartiles (9.06 [SD 4.54] vs 3.57 [SD 2.52], p <0.001) and almost double the number of female interns per program (1.72 [SD 1.42] vs. 0.93 [SD 0.96], < 0.001). In addition, the top quartile contained significantly more programs with dedicated women's sports medicine programs (36.36% vs. 12.40%, p = 0.004). These data and analysis are summarized in Table I.
TABLE I -
Analysis of Top vs. Other Quartile Programs
|
Top Quartile |
Other Quartiles |
p value |
| No. of programs |
33 |
113 |
|
| Total no. of interns |
197 |
526 |
|
| Total no. of female interns |
57 |
103 |
|
| No. of female interns per program |
1.72 (SD 1.42) |
0.93 (SD 0.96) |
<0.001 |
| Total no. of residents |
987 |
2,637 |
|
| Total no. of female residents |
299 |
397 |
|
| No. of residents per program |
23.59 (SD 7.92) |
29.9 (SD 14.5) |
0.001 |
| No. of female residents per program |
9.06 (SD 4.54) |
3.57 (SD 2.52) |
<0.001 |
| Range of female residents in programs |
25%-40% |
0%-19.1% |
|
| Total no. of faculty |
1,429 |
3,715 |
|
| Total no. of female faculty |
190 |
464 |
|
| Percentage of female faculty |
13.30% |
12.50% |
0.46 |
| Female faculty per program |
5.76 (SD 4.68) |
4.18 (SD 3.80) |
0.049 |
| Female full professors per program |
0.939 (SD 1.27) |
0.62 (SD 1.02) |
0.14 |
| Female associate professors per program |
1.3 (SD 1.81) |
1.07 (SD 1.51) |
0.46 |
| No. of female chairpersons |
0 |
6 |
|
| Female chairpersons per program |
0 |
0.05 (SD 0.90) |
0.75 |
| Programs with women's sports medicine programs |
36.36% |
12.40% |
0.004 |
| No. of female program directors/associate program directors per program |
0.303 (SD 0.529) |
0.279 (SD 0.489) |
0.84 |
| No. of female section chiefs per program |
0.515 (SD 0.755) |
0.360 (SD 0.711) |
0.28 |
| No. of female physicians in leadership positions per program |
1.48 (SD 1.68) |
0.088 (SD 1.31) |
0.03 |
Additional comparisons to the 2018 study data are organized in Table II and demonstrate a significant increase in female faculty per program (4.8 [SD 3.85] vs. 3.33 [SD 2.67], p < 0.001) and female full professors (0.694 [SD 1.09] vs. 0.271 [SD 0.667], p < 0.001). There was a decrease in the number of female associate professors; however, this could be attributed to the promotion of more female faculty to full professor (1.13 [SD 1.58] vs. 1.86 [SD 1.95], p < 0.001). The number of female chairpersons increased from 0 to 6 over the 5-year period. In addition, the number of female residency program directors increased (0.29 [SD 0.50] vs. 0.09 [SD 0.29], p < 0.001). These changes contribute to the overall increase in the number of women in leadership positions per program over the past 5 years (1.01 [SD 1.42] vs 0.35 [SD 0.76], p < 0.001).
Table II -
Analysis of 2017 vs. 2022 Data
|
2021-2022 |
2016-2017 |
p value |
| Total female residents |
696 |
485 |
|
| Female residents per program |
4.8 (SD 3.85) |
3.33 (SD 2.67) |
<0.001 |
| Total female faculty |
654 |
396 |
|
| Female faculty per program |
4.54 (SD 4.06) |
2.77 (SD 2.91) |
<0.001 |
| Female full professors per program |
0.694 (SD 1.09)Â |
0.274 (SD 0.667)Â |
<0.001 |
| Female associate professors per program |
1.13 (SD 1.58) |
1.86 (SD 1.95) |
<0.001 |
| Female residency program directors and associate directors per program |
0.29 (SD 0.50) |
0.09 (SD 0.29) |
<0.001 |
| Female physicians in leadership positions per program |
1.01 (SD 1.42) |
0.35 (SD 0.76) |
<0.001 |
Discussion
The sex diversity in orthopaedic surgery and its impact on training programs, professional societies, academic programs, and leadership are widely acknowledged6–9. Yet, investigations regarding the distribution of female residents among orthopaedic surgery residencies in the United States are limited. This study found that programs with higher numbers of female faculty is associated with higher numbers of female residents. In the past 5 years, the percentage of female residents in allopathic orthopaedic surgery residency programs has increased from 13.5% to 19.2%. In addition, the distribution of female interns currently stands at 22.1%. Although promising, the work and initiatives to recruit more female physicians into orthopaedic surgery must continue. We found that 37% of programs (54/146) had no female interns and 9.6% (14/146) of programs had zero female residents during the 2021 to 2022 academic year. Eight programs (5.5%) had no female faculty.
Orthopaedic surgery lags behind all medical and surgical specialties for female representation in the field6–10. Although disparities based on sex persist in orthopaedic surgery, other surgical specialties, most notably general surgery, have been widely successful at reducing these gaps by holistically reviewing resident applicants and investing in longitudinal mentoring programs11. Orthopaedic surgery residency is one of the most competitive residencies in medicine, and there was previously great emphasis on USMLE score thresholds. Because USMLE Step 1 has moved to pass/fail grading, orthopaedic surgery residency programs have needed to re-evaluate their review process. A more comprehensive, holistic review of applicants including valuing nonacademic achievements and attributes may continue to decrease the substantial gap in sex diversity in orthopaedic surgery.
In addition, incorporating orthopaedic surgery as a component of the required general surgery clerkship may expose more female medical students to the field and disprove some of the myths and stereotypes that may be dissuading women from pursuing orthopaedic surgery12. Mentorship is important for female medical students; therefore, both male and female orthopaedic surgeons are pivotal in diversifying the field by serving as mentors, eliminating negative stereotypes, and providing encouragement to prospective female students showing interest in the field3,13,14. The Perry Initiative, Nth Dimensions, and the Ruth Jackson Orthopaedic Society all foster longitudinal mentorship among female high school and medical students. Investment in these programs is crucial for their continued impact in recruiting underrepresented in medicine and female applicants. It has also been observed that some orthopaedic surgery subspecialty societies have lower numbers of female members, fewer women in leadership, and fewer research grants and awards granted to women as compared to men10,15.
Visibility in addition to overall representation is crucial. Our study shows that having more female faculty is associated with more female residents, and therefore, recruitment initiatives that also target female representation within leadership will be vital to changing the future representation in orthopaedic surgery. Programs in the top quartile have more female faculty and were able to recruit a higher number of female interns to matriculate. The cycle of disparity based on sex within orthopaedic surgery may be perpetuated because of programs with limited or absent female faculty who may have difficulty recruiting more female medical students to match at their program.
There are several limitations to our study. Residents and faculty were classified as either women or men and were determined by images and names provided by program's website and pronouns when available. As such, we were limited in our ability to collect data regarding individuals who identify as nonbinary. Because of lack of response from the program or absence of useable information on the program's website, we were unable to evaluate data from 2 orthopaedic residency programs (1.36%); however, this is unlikely to have affected the significance of data collected.
Conclusion
In the past 5 years, the percentage of female residents in allopathic orthopaedic surgery residency programs in the United States has increased from 13.5% to 19.2%. Overall, orthopaedic surgery residency programs with higher percentages of female faculty had higher numbers of female residents. By encouraging programs to diversify faculty and promote female representation within leadership and resident classes, we may begin to see the gap in orthopaedic sex diversity continue to diminish.
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