Introduction
The medical field has a notable history of underrepresentation of women and physicians with minority backgrounds compared with their distribution within the US population1. While in the recent decades, enrollment of female and minority background students in US medical schools has increased dramatically, with 47.8% women and 33.3% minority persons composing the 2015 entering class, they remain underrepresented in many medical and surgical specialties2.
A growing body of evidence demonstrates the negative implications of underrepresentation among health care providers. Patients from minority backgrounds consistently have poorer health and surgical outcomes and higher infant mortality rates than White patients3,4. Although these outcomes cannot be directly attributed to any single cause, there is reasonable concern that insufficient inclusion among medical professionals, inherent biases, and lack of minority persons enrolled in medical studies are influential factors in the quality of care these patients receive. Many patients prefer and feel more able to participate in collaborative decision making with race-concordant providers, resulting in improved screening and follow-through5,6. Some evidence supports that this may be due to differences in surgeon relationship-building and communication skills with non-White patients7 and further evidence suggests both patient outcomes and patient-physician relationships are improved by sharing cultural, racial, or ethnic background8.
A lack of female physicians in certain specialties may also contribute to disparity of care or suboptimal outcomes. Borkhoff et al.9 found that female patients with similar joint disease severity were less likely to undergo joint arthroplasty surgery, noting specifically that female patients were less likely to receive referrals to orthopaedists until they had relatively greater disability and received less medical information in discussion about surgery during consultation than men. The authors hypothesized that physician-related causes of this discrepancy included a lack of patient-centered communication and implicit biases surrounding patient outcomes, support, and caregiver responsibilities. Surgeon-patient sex concordance may be an important factor in improving these measures. Discordance between patients and surgeons contributes to diminished trust, worse adherence to screening protocols, and potentially worse outcomes10–12.
From a patient care perspective, these findings underscore the necessity for a diverse physician workforce for a diverse patient population. However, in surgical subspecialties, and orthopaedics in particular, diversity of both race/ethnicity and sex remain markedly poor. This seems to be due to multiple factors including poor recruiting or absence of targeted recruiting, misconceptions about the specialty, and an outward lack of apparent inclusivity13–15. Noting these trends, the American Medical Association and American Academy of Orthopaedic Surgeons (AAOS) set strategic efforts to encourage physician diversity, including the AAOS placing greater focus on diversity, establishing a diversity advisory board, targeting recruitment efforts, and prioritizing the reshaping of leadership and retention within orthopaedic societies16. Despite these recruitment efforts, civilian orthopaedic minority representation continues to lag behind other subspecialties. The rates of female and minority background physician enrollment in US orthopaedic programs in 2015 were 14.4% and 25.6%, respectively, which was the worst among any surgical specialty13.
Physicians and surgeons in the US Military's health care system train to care for a markedly diverse population of patients including service members, military spouses and family members, and retirees. In 2020, the US military active and reserve populations were similar to the eligible US population, and the larger, enlisted corps of the military were more diverse than the general eligible population17. Despite universal access to health care in the military health system, disparities in health care within the military healthcare system (MHS) persist, albeit to a lesser degree than in the US population as a whole. Reports indicate that while preventative screening may be improved compared with the general population, health, comorbidities, and outcomes still suffer from a clear racial gap18,19. These persistent deficits may be driven by similar institutionalized biases and a lack of physician diversity.
US military physicians are almost universally trained in military or military-funded residency positions. The Uniformed Services University of the Health Sciences and Health Professionals Scholarship Program (HPSP) account for >93% of residents who eventually become military physicians, with only a small proportion of physicians entering after residency training20. To the authors' knowledge, the diversity of military training programs over time has not been previously assessed.
Therefore, the purpose of this study was to analyze diversity in orthopaedic residency programs when compared with other Accreditation Council for Graduate Medical Education (ACGME) military residency programs. We aimed to evaluate the racial/ethnic/sexual composition of applicants accepted for training in military medical and surgical residencies.
Methods
Data Source
The Strengthening the Reporting of Observational Studies in Epidemiology guidelines for reporting both an accurate and complete observational study were followed. After obtaining approval from our institutional review board, we collected information for matriculants into the first year of residency training in the MHS for all years available. For the US Army, Navy, and Air Force, we accessed the available data within the Medical Operational Data System (MODS) starting in 2002, the first year for which data were available, until 2020. In total 9,124 applicants were reviewed across all (medical and surgical) specialties.
Variables
As part of the residency application process, applicants self-report demographic data, including race/ethnicity and sex. These data were available for applicants who matriculated into a military or military-funded residency program. We collected matriculant race/ethnicity, sex, and the medical/surgical specialty program to which they applied and for which they were selected. The percentage of missing data was 0.24% (22/9,124). ACGME primary surgical subspecialty residencies available through MODS were general surgery, neurosurgery, obstetrics and gynecology, ophthalmology, orthopaedic surgery, otolaryngology (ENT), and urology.
Definitions
Racial and ethnic groups were self-selected from a categorical list and included White, Black/African American, Asian/Pacific Islander, Indian/Alaskan Native, Hispanic, multiracial, and other/unknown. Sex was self-reported among available answer choices, which were binary (male vs. female). Although many previous studies consider (or assume) sex, we used matriculant self-reported sex. This was expected to be largely concordant with biologic sex as transgender identity is uncommon in the military, reported between 22.9 and 32.9 per 100,000 among United States military21.
We considered race/ethnicity on the basis of individual groups and for classification as “underrepresented in medicine” (URiM) per the American Academy of Medical Colleges definition, of racial/ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population22. This definition includes Black/African Americans, Native American (American Indians, Alaska Natives, and Native Hawaiians), and mainland Puerto Rican, as well as Hispanic/Latino ethnicity.
Statistical Analysis
Linear regression models were used to evaluate the percentages of accepted applicants who were women and/or identified with racial/ethnic groups. Average annual percentage changes and p values were estimated from separate linear regression models for each surgical subspecialty with year as the independent variable and percent women or minorities as the dependent variable. To evaluate for potential differences in rate of changes of representation among specialties we performed secondary analyses that included interaction terms for specialty and year. All reported p values are 2 sided with the significance level set to <0.05. All analyses were performed using the statistical programming language R (R Core Team 2022).
Results
Overall Sex Data
In total, 2,809 (31%) women selected to residency programs during the study period. Of the 427 applicants selected to orthopaedic programs, 14% (59/427) were women.
Female Residents Entering Surgical Subspecialties
Across all surgical subspecialities, the average annual change in percent women was 0.94% per year for the study period (p < 0.01). The annual change for orthopaedic surgery was 0.10% (p = 0.66), lower than all other surgical subspecialities. Model-estimate annual changes in percent women ranged across specialties from 0.10% to 1.82% per year (Table I).
TABLE I -
Average Percentage of Women in Primary Surgical Specialty Residency Programs by Year
*
| Specialty |
2002 |
2003 |
2004 |
2005 |
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
2013 |
2014 |
2015 |
2016 |
2017 |
2018 |
2019 |
2020 |
Average change per year |
p value |
| General surgery |
0.19 |
0.19 |
0.17 |
0.17 |
0.27 |
0.22 |
0.41 |
0.36 |
0.19 |
0.44 |
0.20 |
0.16 |
0.36 |
0.39 |
0.30 |
0.45 |
0.40 |
0.37 |
0.33 |
1.11 |
<0.01 |
| Neurosurgery |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.20 |
0.00 |
0.25 |
0.67 |
0.00 |
0.00 |
0.50 |
1.82 |
0.02 |
| Obstetrics and gynecology |
0.57 |
0.47 |
0.87 |
0.53 |
0.57 |
0.67 |
0.93 |
0.50 |
0.46 |
0.63 |
0.67 |
0.68 |
0.79 |
0.62 |
0.74 |
0.71 |
0.89 |
0.88 |
0.68 |
1.09 |
0.07 |
| Ophthalmology |
0.25 |
0.14 |
0.14 |
0.43 |
0.40 |
0.50 |
0.14 |
0.00 |
0.33 |
0.00 |
0.00 |
0.00 |
0.38 |
0.00 |
0.29 |
0.20 |
0.17 |
0.33 |
0.60 |
0.22 |
0.78 |
| Orthopaedic surgery |
0.15 |
0.06 |
0.10 |
0.22 |
0.16 |
0.12 |
0.12 |
0.15 |
0.12 |
0.06 |
0.12 |
0.23 |
0.21 |
0.07 |
0.07 |
0.19 |
0.09 |
0.19 |
0.15 |
0.1 |
0.66 |
| Otolaryngology |
0.00 |
0.25 |
0.00 |
0.29 |
0.29 |
0.60 |
0.00 |
0.00 |
0.60 |
0.29 |
0.40 |
0.44 |
0.14 |
0.23 |
0.31 |
0.10 |
0.22 |
0.44 |
0.71 |
1.43 |
0.11 |
| Urology |
0.40 |
0.33 |
0.20 |
0.29 |
0.14 |
0.17 |
0.00 |
0.00 |
0.40 |
0.29 |
0.33 |
0.25 |
0.50 |
0.13 |
0.57 |
0.36 |
0.75 |
0.11 |
0.20 |
0.82 |
0.32 |
| All |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
0.94 |
0.01 |
*Average change and p values are estimated from separate linear regression models for each specialty with years as the independent variable and percent women as the dependent variable. Restricted to common specialties to avoid the misleading appearance of large temporal changes which resulted from small numbers.
Overall URiM Data
There was a total of 1,875 (20%) URiM, 900 (10%) Asian/Pacific Islander, and 6,349 (70%) White applicants selected to residency programs during the study period. Among the 427 medical students who were accepted to orthopaedic training, 81 (19%) were URiM background vs. 26 (6%) Asian/Pacific Islander vs. 320 (75%) White. Of the 81 URiM applicants accepted, 10 were Black, 7 were Hispanic, and 64 identified as other (Appendix 1, https://links.lww.com/JBJSOA/A455). The distributions for other surgical subspecialities are available in Appendix 2 (https://links.lww.com/JBJSOA/A456).
URiM Residents Entering Surgical Subspecialties
Across all surgical subspecialties URiM average annual change was 1.01% per year for the study period (p < 0.01). The average annual percent URiM entering orthopaedic surgery residency programs was 17% for the 18-year study period. The annual change for orthopaedic surgery was 1.52% per year (p < 0.01). Model-estimate annual percent change URiM ranged across specialties from 0.38 to 1.52 (Table II).
TABLE II -
Average Percentage of Underrepresented in Medicine Minorities in Primary Surgical Specialty Residency Programs by Year
*
| Specialty |
2002 |
2003 |
2004 |
2005 |
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
2013 |
2014 |
2015 |
2016 |
2017 |
2018 |
2019 |
2020 |
Average change per year |
p value |
| General surgery |
0.09 |
0.14 |
0.04 |
0.20 |
0.22 |
0.16 |
0.21 |
0.10 |
0.17 |
0.04 |
0.17 |
0.04 |
0.11 |
0.15 |
0.29 |
0.29 |
0.34 |
0.30 |
0.27 |
0.96 |
<0.01 |
| Obstetrics and gynecology |
0.25 |
0.43 |
0.29 |
0.08 |
0.36 |
0.13 |
0.23 |
0.33 |
0.42 |
0.00 |
0.07 |
0.12 |
0.30 |
0.23 |
0.23 |
0.44 |
0.37 |
0.33 |
0.36 |
0.38 |
0.50 |
| Orthopaedic surgery |
0.11 |
0.18 |
0.06 |
0.12 |
0.06 |
0.07 |
0.31 |
0.08 |
0.06 |
0.11 |
0.13 |
0.04 |
0.00 |
0.08 |
0.39 |
0.42 |
0.42 |
0.39 |
0.32 |
1.52 |
0.01 |
| Otolaryngology |
0.00 |
0.25 |
0.00 |
0.29 |
0.33 |
0.25 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.38 |
0.00 |
0.17 |
0.42 |
0.00 |
0.44 |
0.44 |
0.33 |
1.19 |
0.12 |
| All |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1.01 |
<0.01 |
*Average change and p values are estimated from separate linear regression models for each specialty with years as the independent variable and percent minorities as the dependent variable. Restricted to common specialties to avoid the misleading appearance of large temporal changes which resulted from small numbers.
Discussion
The US military is a highly diverse organization comprised persons representative of every group within the general US population. However, there is due concern that the physicians caring for these persons are not similarly diverse, leading to decreased organizational cultural competency, gaps in knowledge or treatment goals, and ability to effectively communicate23. Health professional diversity not only benefits patient access to care, satisfaction with the care/services they receive, and improved medical and surgical outcomes but also improves medical student education12,24,25.
In our cohort, the average annual percent female selection into orthopaedics was 14% for the 18-year study period; however, the annual change for orthopaedic surgery was minimal with only 0.10% per year. Compared with civilian orthopaedic programs, the percentage of physicians accepted for training was lower overall, although there was substantial variability in any given year26,27.
Our findings can be an be considered as a continuation of the Poon et al. findings for women. In their 2016 report, Poon et al.13 observed orthopaedic training was the least representative of women and minorities of any surgical specialty, which was similar to earlier observations by Okike et al.15. Similar to our 14%, they had an average annual percent women of 13.5%. Although their average annual rate of change was higher at 3.5% per year than in our cohort, this was still not on pace with the increasing enrollment of women into medical schools or nearly any other surgical specialty with the exception of urology. Our military rates may be unsurprising given the slower increase in female enrollment in military medical school programs, which increased from 21% between 1980 and 1994 to 27.5% (362/1,318) of Army medical school graduates (Uniformed Services University or HPSP) between 2014 and 201728,29. In the same period, female enrollment in all medical schools increased from representing 32% of the class between 1980 and 1994 to 48% by 2010 to 2015 and higher than 50% in recent years30. Although our current investigation includes an additional 5 years past the end point of their data, the rate of change in female physicians training in orthopaedics shows limited improvement13.
Concurrently, minority representation among all orthopaedic residents decreased at a rate of 3.85% per year with an average annual percent URiM of 25.6%13. Regarding URiM, in our cohort, the average annual percent of military applicants accepted to orthopaedic surgery residency programs was 17% for the 18-year study period. The annual change for orthopaedic surgery was modest at 1.52% per year. Although small, this was a significant, positive rate of change, especially compared with the negative trend seen in the Poon cohort. This was also an important finding because concurrently, nationally, the number of programs without any minority residents has increased from 2002 to 201731. However, there was a notable increase in persons identifying as “other” in our cohort which traditionally identifies persons with heritage or mixed heritage backgrounds in the period from 2016 to 2020. This may reflect an error in documentation vs. an increase in persons identifying with heritage or mixed heritage. If the “other” category is excluded from the definition, the URiM average annual percent orthopaedic surgery residency programs was 4% for the 18-year study period.
Multiple efforts within both the military and civilian orthopaedic communities have attempted to encourage female and minority application. Early exposure to orthopaedics is an important aspect of this paradigm, increasing student interest in orthopaedic surgery. The Perry Initiative and Nth Dimension Internship Program were established as targeted outreach programs to provide early exposure, improve perception of orthopaedics, and increase chances of matching32,33. Although early reports from these programs have been promising, large-scale quantitative effects on overall interest and enrollment from these types of programs are still lacking. Mentorship is also a key component of recruitment, with a majority of medical students reporting it was a moderate or strong influence in choosing their specialty34. Program directors of orthopaedic programs were surveyed for barriers to diversity, with the most common barrier chosen as a lack of minority faculty to encourage minority application35.
Problematically, women and physicians from minority backgrounds make up a disproportionately small component of senior academic faculty26, which may make them less visible as leadership and potential mentors or role models for medical students36. In even the last decade, female surgeons of all specialties comprised less than 25% of their specialty and African American and Hispanic American physicians comprised 3% and 4% of academic surgical faculty at academic institutions, respectively37. In a survey of female orthopaedic surgeons, 69% of respondents reported a lack of strong mentorship in medical school or earlier38. Minority residents were also found to have fewer mentors and be more dissatisfied with their mentorship34. These findings may provide some evidence as to why despite these increasing recruitment efforts, we have as a specialty observed minimal changes in numbers of minority and female trainees.
Before exposure through an orthopaedic rotation or musculoskeletal experience, many female and minority medical students do not carry a positive perception of orthopaedic surgery39. However, despite great efforts to increase exposure, through outreach programs and musculoskeletal rotations, there appears to be little change in diversity within the field of orthopaedics. Therefore, the focus many need to shift to not only exposure but rather to efforts demonstrating subspecialty appeal. In modern society, female and male orthopaedic surgeons have different expectations for work-family integration, and female physicians are vulnerable to conflicting responsibility with societal and cultural roles40. It is imperative that administratively we demonstrate a supportive infrastructure to help navigate unique challenges that may predispose female (as well as URiM) orthopaedic surgeons to poor work-family integration. This may be an additional barrier to otherwise highly qualified, diverse applicants.
There are several limitations to the current study. First, this is a retrospective database review which can account for trends in enrollment behavior, but cannot explain the reasoning for application, the acceptance rate, or the reasons a person might be accepted such as test scores or other experience. Second, all data were self-reported by applicants and therefore could be prone to error in accuracy, particularly when a person might be multiracial or belong to a group not well captured by one of the options. This is particularly concerning in the setting of the increased number of matriculants identified as “other” in the final years of available data because there is no clear explanation for this trend and may reflect an error rather than a true trend. In addition, based on the limited options of the data reporting systems, we were unable to specifically consider applicants with Pacific Islander background in the definition of URiM. However, uniquely as compared to similar studies, our data are directly self-reported, and therefore, the percentage of missing data was only 0.24%. Next, it is unclear from our data what proportion of applicants may have identified with a gender other than their biologic sex, and it is therefore impossible to account for whether orthopaedic selection bias is more attributable to applicant sex or gender. In addition, we do not know the percent of overall applicants who were not selected and/or went into other subspecialties not matching to orthopaedics.
Conclusion
Orthopaedic surgery training programs in both civilian and military systems suffer from a lack of sexual, ethnic, and racial diversity. This lack of diversity has a detrimental impact on the quality of training and on delivery of high-quality care to patients. Although there have been some improvements in resident diversity, we can do better. Change will require continued, focused efforts to improve outreach to medical school and earlier education levels, dissolution of negative perceptions about orthopaedics, recruitment and retention of diverse faculty, and increased education and awareness of racial and sexual disparities in health care.
Appendix
Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (https://links.lww.com/JBJSOA/A455 and https://links.lww.com/JBJSOA/A456). This content was not copyedited or verified by JBJS.
Note: The authors thank the Department of Defense Graduate Medical Education (GME) and Rear Admiral Upper Half Bruce L. Gillingham for facilitating data acquisition. The authors also thank Dr. Nora L. Watson, PhD, for epidemiological and biostatistical reviews.
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