Introduction
Increasing ethnoracial and sexual diversity among orthopaedic residency programs is the primary means of diversifying the field of orthopaedic surgery1. Orthopaedic residency program directors (PDs) play a critical role in developing and sustaining a culture of diversity, equity, and inclusion (DEI) in the field2. They are in a unique position to lead cultural change by impressing a sense of urgency around addressing DEI topics, encouraging a more diverse group of applicants through recruitment practices, advocating for representation, and addressing DEI issues through curricular and cultural change2.
Previous studies have examined the demographic makeup of spine surgery, foot and ankle, sports medicine, shoulder and elbow, adult reconstruction, and pediatric orthopaedic fellowship directors (FDs)3–8. Each study reported a paucity of female and minority representation among FDs3–9. To date, there has been a lack of studies that have examined the characteristics and demographics of orthopaedic residency PDs. However, the role of PDs in increasing diversity among orthopaedic trainees may far outweigh those of FDs.
The purpose of this study is to (1) examine the demographic makeup including age, sex, and race/ethnicity and (2) characterize trends including research productivity, training history, residency and fellowship graduation year, advanced degrees, military affiliation, program loyalty, year hired, and career timeline of orthopaedic residency PDs in 2022. This article aims to highlight and address diversity in orthopaedics from a top-down approach.
Materials and Methods
Data Collection
The Accreditation Council for Graduate Medical Education (ACGME) Residency Program Directory along with the National Resident Matching Program Data Report for 2022 was used to identify all PDs of all accredited orthopaedic surgery residency training programs in the United States10,11. Demographic and educational background data were gathered by 1 independent reviewer (P.E.C.) from publicly available curriculum vitae, LinkedIn, Healthgrades, Doximity, and/or institutional biographies and consolidated into a database. Demographic information included sex, race/ethnicity, and age. Educational data included dual-degree status, medical school, residency institution, specialty certifications, residency graduation year, number of fellowships, fellowship institution, program loyalty defined as any portion of (medical school through fellowship) training completed at the program the PD is currently appointed, year fellowship ended, year appointed PD, time from residency to PD appointment, time from starting at institution to PD, years spent as PD, previous or current appointment as the president of a major orthopaedic society, and military affiliation. In addition, research metrics such as personal research h-index, number of publications in PubMed, number of publications at time of appointment, history of National Institutes of Health (NIH)/Howard Hughes Medical Institute (HHMI) funding, and total number of citations were collected.
The h-index is a metric of scientific productivity and impact defined as the maximum value of h such that the author in question has published h articles that have each been cited a minimum of h times12. For instance, an author with an h-index of 5 has 5 scientific publications that have each been cited a minimum of 5 times. To obtain the h-index and total number of citations for each PD, the physician was searched on the Scopus database (Elsevier BV). This database tracks scientific productivity metrics such as the h-index, total number of citations, and total number of notifications per author13.
Statistical Analysis
The statistical analysis was performed using BlueSky 7.4.0 software (BlueSky Statistics). Descriptive statistics were used to present characteristics with proportions, percentages, means, standard deviations, and ranges, as necessary. Pearson correlation coefficients were used with the Mukaka guide on correlation coefficients in medical research settings14. Therefore, correlation coefficient values less than 0.4, 0.4 to 0.7, and 0.7 to 0.9, and greater than 0.9 are suggestive of weak, moderate, strong, and very strong positive correlations, respectively15. All tests were two-sided, and a p value of < 0.05 was considered statistically significant.
Results
According to the ACGME, there are a total of 210 orthopaedic surgery residency training programs currently accredited for the 2021 to 2022 academic year. This study collected data on 210 (100%) orthopaedic surgery PDs (Table I). Of the 210 PDs, 188 (89.5%) were male and 22 (10.5%) were female, with an average age of 52.9 ± 9.0 years (n = 155). Regarding ethnicity and race, 174 (82.9%) were non-Hispanic White, 14 (6.7%) were Asian American and/or Pacific Islanders, 12 (5.7%) were Black or African American, 4 (1.9%) were Hispanic or Latino, and 6 (2.9%) were other/unknown race. A majority (90.5%) of PDs did not have an additional advanced degree while 20 (9.5%) had one or more advanced degrees (2 PhD, 6 MS, 6 MBA, 1 MEd, 4 MPH, and 1 MA). A total of 24 (11.4%) PDs had a military affiliation or appointment. Moreover, the average number of publications held by PDs was 13.0 ± 17.4 (n = 71) at the time of appointment and 33.9 ± 51.0 (n =208) to date, with an average of 801.9 ± 1,536.4 (n = 187) citations as of August 2022. The average h-index of PDs was 10.5 ± 9.5 (n = 199), with 7 (3.6%) PDs having a history of NIH or HHMI grant funding.
TABLE I -
Demographics, Research Background, and Leadership appointments of Orthopaedic Surgery PDs
| PD leadership |
|
| Total no. of orthopaedic residency programs |
210 |
| Total no. of orthopaedic residency PDs |
210 |
| Demographic characteristics |
|
| Sex, n (%) |
|
| Male |
188 (89.5) |
| Female |
22 (10.5) |
| Age, mean ± SD (yr) |
52.9 ± 9.0 (n = 155) |
| Race/ethnicity, n (%) |
|
| Non-Hispanic White |
174 (82.9) |
| Asian American and Pacific Islander |
14 (6.7) |
| Black or African American |
12 (5.7) |
| Hispanic or Latino |
4 (1.9) |
| Other |
6 (2.9) |
| Advanced degrees, n (%) |
|
| None |
190 (90.5) |
| Doctor of Philosophy |
2 (1.0) |
| Master of Science |
6 (2.9) |
| Master of Business Administration |
6 (2.9) |
| Master of Education |
1 (0.5) |
| Master of Public Health |
4 (1.9) |
| Master of Art |
1 (0.5) |
| Training and research |
|
| Military affiliation, n (%) |
24 (11.4) |
| No. of publications at the time of PD appointment, mean ± SD |
13.0 ± 17.4 (n = 71) |
| No. of publications to date, mean ± SD |
33.9 ± 51.0 (n = 208) |
| No. of total citations, mean ± SD |
801.9 ± 1,536.4 (n = 187) |
| PD Scopus h-index, mean ± SD |
10.5 ± 9.5 (n = 199) |
| History of NIH or HHMI funding |
7 (3.6%) (n = 197) |
| Major orthopaedic surgery leadership appointments, n (%) |
|
| Previous or current appointment as the president in a major society |
8 (3.8) |
| American Osteopathic Association |
4 (2.0) |
| American Academy of Orthopaedic Surgeons |
1 (0.5) |
| American Orthopaedic Foot and Ankle Society |
1 (0.5) |
| American Association of Latino Orthopaedic Surgeons |
1 (0.5) |
| Ruth Jackson Orthopaedic Society |
1 (0.5) |
HHMI = Howard Hughes Medical Institute, NIH = National Institutes of Health, and PD = program director.
The average year of graduation from residency was 2003 ± 9.2 (n = 205) and fellowship was 2005 ± 9.1 (n = 154). A majority of PDs completed 1 fellowship (83.8%), whereas few completed none (9.5%) or 2 (6.7%). On average, it took 10 ± 6 years (range, 0-24 years) to be appointed as PD from the completion of training; moreover, it took an average of 7 ± 6 years (range, 0-24 years) to be appointed as PD from the year of hire. PDs were most commonly subspecialty trained in orthopaedic traumatology (19.5%), sports medicine (15.7%), or hand surgery (11.9%), with the remaining PDs being composed of general orthopaedics (9.5%), foot and ankle (9.0%), adult reconstruction (7.1%), spine surgery (7.1%), pediatric orthopaedics (6.2%), orthopaedic oncology (6.2%), shoulder and elbow (3.3%), or multiple fellowship (4.3%) trained surgeons (Table II). Current PDs have served in their role for an average of 8.9 ± 6.2 years to date. Regarding institutional loyalty, 30 (14.3%) PDs were employed at the same institution where they graduated from medical school. Eighty-one (38.6%) were employed at the same institution where they completed their residency. Few (6.2%) were employed at an institution where they completed a fellowship (Table II). Nearly 60% of PDs demonstrated some degree of program loyalty, whereas approximately 40% were appointed at an institution where they did not complete their medical education or surgical training.
TABLE II -
Education and Employment History of Orthopaedic Surgery PDs
| Education and progression of employment |
|
| Residency graduation calendar year, mean ± SD |
2003 ± 9.2 (n = 205) |
| Fellowship graduation calendar year, mean ± SD |
2005 ± 9.1 (n = 154) |
| No. of fellowships, n (%) |
|
| 0 |
20 (9.5) |
| 1 |
176 (83.8) |
| 2 |
14 (6.7) |
| Fellowship subspecialty training, n (%) |
|
| None |
20 (9.5) |
| Trauma |
41 (19.5) |
| Sports medicine |
33 (15.7) |
| Hand |
25 (11.9) |
| Foot and ankle |
19 (9.0) |
| Adult reconstruction |
15 (7.1) |
| Spine |
15 (7.1) |
| Pediatrics |
13 (6.2) |
| Oncology |
13 (6.2) |
| Shoulder and elbow |
7 (3.3) |
| Multiple fellowships |
9 (4.3) |
| Time to PD appointment from completion of training, mean ± SD (yrs) |
10.0 ± 6.2 |
| Time from year of hire to year of PD appointment, mean ± SD (yrs) |
7.1 ± 6.0 |
| Time in the current PD role |
8.9 ± 6.2 |
| Institutional loyalty, n (%) |
|
| PD currently working at the same institution as medical school graduation |
30 (14.3) |
| PD currently working at the same institution as residency graduation |
81 (38.6) |
| PD currently working at the same institution as fellowship graduation |
13 (6.2) |
| Correlation with the Scopus h-index |
|
| Years as PD vs. Scopus h-index |
r = 0.14 (p = 0.276) |
| Age vs. Scopus h-index |
r = 0.38 (p = 0.024) |
The medical schools that produced at least 4 future orthopaedic surgery PDs were Temple University Lewis Katz School of Medicine (n = 6), University of Illinois College of Medicine at Chicago (n = 6), Georgetown University School of Medicine (n = 5), Harvard Medical School (n = 5), Rutgers University New Jersey Medical School (n = 5), Thomas Jefferson University Sidney Kimmel Medical College (n = 5), and Uniformed Services University of the Health Sciences (n = 5). In addition, 64 programs produced 1 PD, 21 programs produced 2 PDs, and 16 programs produced 3 PDs. Medical schools with ≥ 4 PD affiliations are included in Figure 1.
;)
Fig. 1: Most frequently attended medical schools for current orthopaedic surgery program directors (PDs). All medical schools with a minimum of 4 previous PD graduates are included.
The residency programs that produced at least 4 orthopaedic surgery PDs were Hospital for Special Surgery (n = 6), Michigan State University—Lansing (n = 4), University of Michigan (n = 4), Walter Reed Army Medical Center (n = 5), and Western Reserve Hospital (n = 4). In addition, 90 programs produced 1 PD, 27 programs produced 2 PDs, and 11 programs produced 3 PDs. Orthopaedic surgery residency training programs with ≥ 4 PD affiliations are included in Figure 2.
Fig. 2: Most frequently attended residency training programs for current orthopaedic surgery program directors (PDs). All medical schools with a minimum of 4 previous PD graduates are included.
Orthopaedic surgery fellowship programs that produced the most PDs were from Harvard affiliates, including Massachusetts General, Brigham and Women's, and Beth Israel (n = 13); Hospital for Special Surgery (n = 7); Thomas Jefferson University Sidney Kimmel Medical College (n = 6); and University of Washington (n = 6). In addition, 69 programs produced 1 PD, 19 programs produced 2 PDs, and 12 programs produced 3 PDs. Programs with ≥ 4 PD affiliations are included in Figure 3.
Fig. 3: Most frequently attended fellowship training programs for current orthopaedic surgery program directors (PDs). All medical schools with a minimum of 4 previous PD graduates are included.
Pearson correlation coefficient calculations revealed a nonsignificant, weak correlation between the number of years served as PD and h-index (r = 0.14, p = 0.276). Conversely, Pearson correlation coefficient calculations demonstrated a significant, weak correlation between PD age and h-index (r = 0.38, p = 0.024) (Table II). Figure 4 demonstrates the spread of h-index of orthopaedic surgery PDs.
Fig. 4: Overview of Scopus h-indices (as of July 6, 2022) for all orthopaedic surgery residency program directors.
Discussion
Overall, this study found that orthopaedic surgery residency PDs are primarily White men in their early 50s with strong program loyalty. Over 50% of PDs were appointed at institutions where they completed medical school, residency, or fellowship training. Furthermore, current PDs have served in their role for 8.9 years on average and were appointed as PD approximately 10 years after completion of training. The most common fellowships for PDs were orthopaedic traumatology, sports medicine, and hand surgery.
As of 2020, women made up 50.5% of the US population, 16% of orthopaedic surgery resident trainees, and 6.5% of active orthopaedic surgeons16–18. Our study found that women made up 10.5% of PDs. Although still behind the upward trend of women entering orthopaedic training residency programs, this is well-above female representation for FDs in sports medicine (3.3%), spine surgery (3.9%), adult reconstruction, and shoulder and elbow (2.5%)4–6. The relatively strong female representation among PDs mimics that of pediatric orthopaedics, which reports 11% female FDs as of 20213. Notably, women made up 25% of pediatric orthopaedic fellows in 2014, which is higher than that of the whole orthopaedic workforce from which PDs are chosen19,20. Interestingly, women are more represented in the proportion of active PDs compared with their proportion in the body of total active orthopaedic surgeons. This may be influenced by subjective factors such as leadership, communication skills, and interest in education, as well as a program's desire to promote women into leadership positions.
A similar trend was observed with minority representation among PDs. The US population is 40.7% non-White while non-White trainees make up 25.6% of the orthopaedic surgery resident workforce19,21. Our study found 17.1% non-White PDs. Poon et al. showed that 12.5%, 4.2%, 0.36%, 0.19%, and 8.3% of orthopaedic surgery residents were Asian, Black, American Indian Alaska Native, Native Hawaiian or other Pacific Islander, and other/unknown, respectively21. The present study found that 6.7%, 5.7%, 1.9%, and 2.9% of PDs were Asian and/or Pacific Islander, Black or African American, Hispanic or Latino, and other/unknown, respectively. Notably, Black or African American and Hispanic or Latino were overrepresented in the proportion of PDs compared with their proportions in the general orthopaedic workforce. Again, this is most likely shaped by subjective criteria such as passion for diversifying the field, interest in education, and leadership skills that this study was not able to assess. Similarly, programs desire for improving representation may be a driving force in ethnoracial and sexual minority representation in PD positions. Although the overall orthopaedic workforce does not yet mirror the diversifying demographics of the United States, medical schools, and orthopaedic surgery residency programs19,21,22, the increases in the proportion of ethnoracial and sexual minorities serving as PD elucidated in this study is a positive trend. Indeed, studies have demonstrated that female and minority applicants are more likely to matriculate into orthopaedic surgery when their institution had faculty members from concordant backgrounds22,23.
A majority (90.5%, n = 190) of PDs did not have additional advanced degrees. Among those with an additional advanced degree, the most common were Master of Science (2.9%, n = 6) and Master of Business Administration (2.9%, n = 6). Military affiliation was more common than an additional advanced degree (11.4%, n = 24). This may be attributable to subjective characteristics such as leadership skills, communication, and interest in education that may be emphasized in military training. Most PDs completed 1 fellowship (83.8%, n = 176), 9.5% (n = 20) completed no fellowship, and 6.7% (n = 14) completed 2. PD appointment was not associated with an increased number of fellowships. The most common fellowships completed were orthopaedic traumatology (19.5%, n = 41), sports medicine (15.7%, n = 33), and hand surgery (11.9%, n = 25).
The medical schools that produced the most PDs were University of Illinois College of Medicine at Chicago (n = 6) and Temple University Lewis Katz School of Medicine (n = 6). The residency program that produced the most PDs was Hospital for Special Surgery (n = 6), followed by Walter Reed Army Medical Center (n = 5). Furthermore, the fellowship that produced the most PDs was Harvard Medical School (n = 13), followed by Hospital for Special Surgery (n = 7). Compared with their FD counterparts, there was a larger variance in institutions attended4,6,8. Furthermore, appointment as PD seems to be less associated with the individual training program attended and more associated with the individual's institutional loyalty to said training program because 59.1% of PDs were appointed at an institution that they had an affiliation. This is similar to a study by Elahi et al. that showed 61.7% of foot and ankle FDs were appointed at institutions they had an affiliation8. Similarly, 14.3% (n = 30), 38.6% (n = 81), and 6.2% (n = 13) of PDs are currently working at the same institution where they graduated from medical school, residency, and fellowship, respectively. Unfortunately, the substantial proportion of PDs who have institutional loyalty may be a factor limiting the diversification of orthopaedic surgery leadership given the potential lack of ethnoracial, socioeconomic, geographic, and sexual diversity when selecting from a small pool of training programs. In addition, the mean tenure as PD was 8.9 years to date, and the mean time from training completion to PD appointment was 10 years. This is similar to the mean tenure and time to appointment of sports medicine FDs, which was 9.3 years and 12.8 years, respectively6.
On average, orthopaedic surgery residency PDs had less research productivity when compared with sports medicine, adult reconstruction, foot and ankle, shoulder and elbow, spine, and pediatric orthopaedic FDs3,4,6,8,9. The mean Scopus h-index was 10.5. This is compared with 24.1, 16.4, 13.3, 24.6, 23.8, and 17.2 for sports medicine, adult reconstruction, foot and ankle, shoulder and elbow, spine, and pediatric orthopaedic FDs, respectively3–8. This is likely multifactorial and may be secondary to high subspecialization among FDs, higher associated dedicated workload associated with working as a PD, higher volume of trainees to monitor/mentor in residencies in comparison to fellowships, and differing interests between FDs and PDs, among other factors. In addition, the choice to appoint an individual as PD is multifactorial and considers qualities beyond the scope of this article, with research productivity only being part of the equation.
There are several limitations to this study. All data points that were not available in the ACGME Residency Directory were obtained from publicly accessible curriculum vitae, websites, and/or institutional biographies. As a result, some information may be missing. In addition, this study was limited by the public availability of selected data points. Thus, complete characteristic and demographic results could not be obtained for every PD. Therefore, some pieces of data with lower public availability such as year appointed PD and time spent as PD may be less representative of the entire orthopaedic PD population. Furthermore, sex and race/ethnicity were determined by publicly available information including images provided through institutional websites and biographies. Thus, there was subjectivity into categorization into the major racial and sexual groups. In addition, there are many subjective factors that contribute to the qualities of highly effective leaders that are not captured in this review. Finally, this study represents a cross-sectional representation of orthopaedic surgery residency PDs at a single point in time.
Conclusion
Overarchingly, orthopaedic surgery PDs are White men in their early 50s. Notably, there is minimal female (10.5%) and minority representation (17.1%). However, we see a higher proportion of female, Black or African American, and Hispanic or Latino representation among PDs when compared to their proportion in the overall orthopaedic surgery workforce. PD appointments may be less dependent on research productivity when compared to FD appointments. Program loyalty seems to play an important role in PD appointment, with many PDs being appointed at an institution where they had a training affiliation.
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