Abstract
Introduction:
Gender representation among orthopaedic surgery applicants and residents has increased over the past two decades. The aims of this study were to evaluate trends of female fellows in ACGME-accredited orthopaedic subspecialties between 2007 and 2021, and to compare the fellowship trends of female representation to those of ACGME-accredited orthopaedic residencies.
Methods:
We conducted a retrospective review of publicly available ACGME-accredited fellowship demographic data from 2007 to 2021. The distribution of genders (male vs. female) across subspecialties and orthopaedic surgery residency programs was compared. Chi-square, Spearman correlation, and logistic regression tests were performed to analyze the relationships between year, gender, and fellowship.
Results:
Chi-square analysis demonstrated a significant relationship between gender and year for orthopaedic residency (p < 0.001), but not for any fellowship. There was a significant negative Spearman correlation between the two variables for hand (r(1844) = −0.06, p = 0.02) and sports medicine (r(2804) = −0.05, p = 0.01) fellowships. The negative Spearman correlation for pediatrics (r(499) = −0.09, p = 0.054) approached but did not reach statistical significance. Logistic regression analysis revealed that, holding year constant and comparing to orthopaedic residency, the odds of male participation increased by 173% (95% CI, 1.8–4.1) in spine, increased by 138% (95% CI, 1.7–3.3) in adult reconstruction, increased by 51% (95% CI, 1.3–1.7) in sports medicine, decreased by 41% (95% CI, 0.5–0.7) in hand, decreased by 36% (95% CI, 0.5–0.9) in foot and ankle, decreased by 48% (95% CI, 0.4–0.7) in musculoskeletal oncology, and decreased by 68% (95% CI, 0.3–0.4) in pediatrics.
Conclusion:
Although the percentage of female orthopaedic residents in ACGME-accredited programs increased significantly from 2007 to 2021, this has not translated to ACGME-accredited fellowship positions. Future research optimizing methods to improve the representation of females in orthopaedic surgery should be considered.
Level of Evidence:
III
Introduction
Approximately 54% of all first-year medical students are female1. Equal gender representation has not been reflected in historically male-dominated surgical fields, such as orthopaedic surgery2. Compared with all other subspecialties, orthopaedic surgery has consistently demonstrated the lowest percentage of female residents over the past decade, totaling 16% in 20203.
In 2019, 19% of the medical students applying to Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery residency programs were female, which was significantly disproportionate to the 15% of female residents who matriculated during that same year4. When accounting for females in both residency and fellowship positions during the same year, this proportion further drops to 13%5,6. However, the current literature evaluating the gender diversity between residency and fellowship positions is sparse7,8.
The aims of this study were to (1) evaluate trends of female fellows in ACGME-accredited orthopaedic subspecialties between 2007 and 2021 and (2) compare the fellowship trends of female representation to those of ACGME-accredited orthopaedic residencies. Recruitment and retention of females within orthopaedic surgery continue to be critical if the objective remains for physician demographics to resemble those of the populations they serve.
Methods
We performed a retrospective review of orthopaedic surgery demographic data from 2007 to 2021 as published in the online ACGME Data Resource Book series6. Institutional Review Board approval was not required, given the public and anonymous nature of the data set provided by the ACGME. Our study evaluated gender demographics (male vs female) of orthopaedic residents, as well as fellows in adult reconstruction, foot and ankle, hand, sports medicine, musculoskeletal oncology, spine, trauma, and pediatrics. Shoulder and elbow fellowship data were not available in the data set. The Statistical Package for the Social Sciences software was used for data analysis. The Pearson χ2 test of independence was used to test for association. Logistic regression was used to analyze the relationship between year, fellowship, orthopaedic residency, and gender. A Spearman test was used to assess correlation of values. The level of significance was set at p < 0.05.
Results
There were a total of 2,320 ACGME-accredited orthopaedic surgery residency and fellowship program cohorts (Figs. 1 and 2) containing 51,856 active trainees between 2007 and 2021, but 1,935 of these individuals did not choose to self-identify as male or female. We included the remaining 49,921 residents and fellows, of which 42,756 were males (Fig. 3) and 7,165 were females (Fig. 4).
Fig. 1.
The number of ACGME-accredited orthopaedic surgery residency and fellowship programs from 2007 to 2021. ACGME = Accreditation Council for Graduate Medical Education.
Fig. 2.
The number of ACGME-accredited orthopaedic surgery residency and fellowship positions from 2007 to 2021. ACGME = Accreditation Council for Graduate Medical Education.
Fig. 3.
The number of females within ACGME-accredited orthopaedic surgery residency and fellowship programs from 2007 to 2021. ACGME = Accreditation Council for Graduate Medical Education.
Fig. 4.
The number of males within ACGME-accredited orthopaedic surgery residency and fellowship programs from 2007 to 2021. ACGME = Accreditation Council for Graduate Medical Education.
A χ2 test was performed to examine the relationship between gender and year (2007-2021) in orthopaedic residency and each subspecialty fellowship. The relationship between these variables was not significant for any fellowship but was significant for orthopaedic residency positions (p < 0.001). Pearson χ2 values for each specialty and the total number of filled positions are included in Table I.
TABLE I.
The Association Between Gender and Year Within General Orthopaedic Residency and Subspecialty Fellowships From 2007 to 2021
| Specialty | Pearson χ2 | p Value | n |
|---|---|---|---|
| Orthopaedic residency | 64.2 | <0.001 | 49,921 |
| Adult reconstruction | 12.6 | 0.5 | 545 |
| Foot and ankle | 11.6 | 0.6 | 223 |
| Hand | 20.7 | 0.08 | 1,846 |
| Musculoskeletal oncology | 9.4 | 0.7 | 203 |
| Pediatrics | 20.9 | 0.07 | 499 |
| Spine | 6.1 | 0.9 | 437 |
| Sports medicine | 13.6 | 0.4 | 2,806 |
| Trauma | 11.6 | 0.6 | 238 |
Spearman correlation was computed to assess the relationship between the number of males (Fig. 3) and females (Fig. 4) within orthopaedic residency and each subspecialty fellowship between 2007 and 2021. There was a significant negative correlation between the 2 variables for hand (r [1,844] = −0.06, p = 0.02) and sports medicine (r [2,804] = −0.05, p = 0.01) fellowships. The negative correlation for pediatrics (r [499] = −0.09, p = 0.054) approached but did not reach statistical significance. Spearman correlation results are reported in Table II.
TABLE II.
The Correlation Between the Number of Males and Females Within General Orthopaedic Residency and Subspecialty Fellowships From 2007 to 2021
| Specialty | Spearman Correlation | p Value | n |
|---|---|---|---|
| Orthopaedic residency | −0.04 | <0.001 | 49,921 |
| Adult reconstruction | −0.02 | 0.6 | 545 |
| Foot and ankle | −0.08 | 0.2 | 223 |
| Hand | −0.06 | 0.02 | 1,846 |
| Musculoskeletal oncology | 0.02 | 0.8 | 203 |
| Pediatrics | −0.09 | 0.054 | 499 |
| Spine | −0.05 | 0.3 | 437 |
| Sports medicine | −0.05 | 0.01 | 2,806 |
| Trauma | −0.09 | 0.1 | 238 |
Logistic regression analysis was used to analyze the relationship between year, fellowship, orthopaedic residency, and gender. Holding year constant and comparing with orthopaedic residency, the odds of male participation increased by 173% (95% CI [1.8-4.1]) in spine, increased by 138% (95% CI [1.7-3.3]) in adult reconstruction, increased by 51% (95% CI [1.3-1.7]) in sports medicine, decreased by 41% (95% CI [0.5-0.7]) in hand, decreased by 36% (95% CI [0.5-0.9]) in foot and ankle, decreased by 48% (95% CI [0.4-0.7]) in musculoskeletal oncology, and decreased by 68% (95% CI [0.3-0.4]) in pediatrics. There were no significantly different odds of male representation between trauma and orthopaedic residency (95% CI [0.7-1.4]). Odds ratios and associated confidence intervals are reported in Table III. When fellowship and residency were held constant, the odds of male representation decreased by 3% (95% CI [0.97-0.98]) for each year.
TABLE III.
Probability of Male Representation Within Orthopaedic Subspecialty Fellowships as Compared to Residency Programs From 2007 to 2021
| Specialty | Odds Ratio | 95% Confidence Interval | |
|---|---|---|---|
| Lower | Upper | ||
| Spine | 2.7 | 1.8 | 4.1 |
| Adult reconstruction | 2.4 | 1.7 | 3.3 |
| Sports medicine | 1.5 | 1.3 | 1.7 |
| Trauma | 1.0 | 0.7 | 1.4 |
| Foot and ankle | 0.6 | 0.5 | 0.9 |
| Hand | 0.6 | 0.5 | 0.7 |
| Musculoskeletal oncology | 0.5 | 0.4 | 0.7 |
| Pediatrics | 0.3 | 0.3 | 0.4 |
The range of percentages of female trainees in each subspecialty from the years 2007 to 2021 is included to assist as a reference point (Table IV).
TABLE IV.
Ranges of Percentages of Female Trainees in Each Specialty From 2007 to 2021
| Female Gender (%) | |
|---|---|
| Orthopaedic residency | 11.6-16.7 |
| Adult reconstruction | 0.0-12.5 |
| Foot and ankle | 0.0-37.5 |
| Hand | 15.6-31.6 |
| Musculoskeletal oncology | 9.1-43.8 |
| Sports medicine | 5.0-12.7 |
| Spine | 0.0-9.7 |
| Trauma | 0.0-25.0 |
| Pediatrics | 11.4-51.5 |
Discussion
The principal finding of our study is that although the percentage of female orthopaedic residents in ACGME-accredited programs increased significantly from 2007 to 2021, the number of female fellows among every subspecialty did not demonstrate any significant changes during this same time. This highlights that despite recruitment of more females to orthopaedic surgery residency programs, this has not translated to ACGME-accredited fellowship positions.
We examined each subspecialty to identify subspecialties with higher levels of upward mobility, and our results demonstrate that the female representation of hand (p = 0.02) and sports medicine (p = 0.01) fellows relative to male fellows is increasing each year. This suggests that the gender distribution gap is closing within these 2 orthopaedic subspecialties. The Spearman correlation values for adult reconstruction, foot and ankle, musculoskeletal oncology, pediatrics, spine, and trauma were not significant, although the value for pediatrics was borderline significant (p = 0.054). This is consistent with recent literature identifying the most common subspecialties pursued by female orthopaedic surgeons as hand (24%), pediatric (19%-23%), and sports medicine (15%-16%) fellowships.9,10
We further analyzed the data in a logistic regression to better understand the current ratios of genders within each fellowship. Subspecialties such as pediatrics (OR = 0.3, 95% CI: 0.3-0.4), musculoskeletal oncology (OR = 0.5, 95% CI: 0.4-0.7), hand (OR = 0.6, 95% CI: 0.5-0.7), and foot and ankle (OR = 0.6, 95% CI: 0.5-0.9) saw decreased odds of male representation over time when compared with orthopaedic residency. Sports medicine (OR = 1.5, 95% CI: 1.3-1.7), adult reconstruction (OR = 2.4, 95% CI: 1.7-3.3), and spine (OR = 2.7, 95% CI: 1.8-4.1) fellowships demonstrated increased odds of male representation over time when compared with orthopaedic residency positions.
Female orthopaedic surgery residents applying to fellowships in the 2010 to 2014 academic years had a significantly higher probability of matching when compared with males (96% vs 81%, p < 0.001)11. Although this study offers insight into the proportion of fellowship trainees within a short period, it did not analyze trends within fellowships or compare those trends with orthopaedic residency. In addition, these proportions may not fully represent the orthopaedic female residents during this time because it comprised a small subset of applicants taken from an already minority group of residents11.
It is critical to note that not all orthopaedic fellowships are recognized by the ACGME and were therefore not included in our data set. A recent study by Silvestre et al. compared the proportion of ACGME-accredited orthopaedic surgery fellowship programs during 2013 and 2021 and found no difference between them (53% vs 48%, p = 0.17, respectively). However, a significant reduction in ACGME-accredited positions was noted when comparing 2013 and 2021 (58% vs 50%, p < 0.001, respectively), which the authors attributed to a significant reduction in pediatrics training positions (59% vs 37%, p = 0.01)12. Similarly, we found the pediatric subspecialty to have the significantly lowest odds of male representation when compared with orthopaedic surgery residency programs (OR = 0.3, 95% CI: 0.3-0.4). Certain specialties, such as hand, require graduation from ACGME-accredited fellowships to qualify for subspecialty certificates. Adult reconstruction does not have this requirement, which may explain the trend of particular specialties increasing or decreasing in ACGME accreditation.
Both sports medicine and hand fellowships have had significant increases in accredited programs during a similar timeframe as our study (93% vs 100%, p = 0.02 and 81% vs 99%, p < 0.001, respectively)12, indicating that both increased female representation and increasing accreditation in sports medicine and hand programs are occurring simultaneously. By contrast, the number of ACGME-accredited adult reconstruction fellowship programs significantly decreased during this time (40% vs 24%, p = 0.04)12, but our results showed these programs to have significantly higher odds of male representation at 138% (OR = 2.4, 95% CI [1.7-3.3]).
Finally, our analysis showed that although holding fellowship and orthopaedic surgery residency constant, the odds of being male decreased by 3% (95% CI: 0.97-0.98) for each year. The increased recruitment of female orthopaedic residents has not distributed equally among ACGME-accredited fellowships, but our data are encouraging with suggestions that gender representation is normalizing8-10.
Bratescu et al. conducted a survey of practicing orthopaedic female surgeons, fellows, and fellowship-matched residents investigating subspecialty choice and found that strong mentorship was the most impactful extrinsic/modifiable factor that affected the decision-making process9. Shah et al. investigated gender diversity at varying academic levels and found that although the amount of female orthopaedic surgeons in faculty positions increased from 9% in 1997 to 18% in 2017, these opportunities were considerably more likely for a junior rather than senior position (p < 0.001)13. A national review of diversity among subspecialty leadership similarly found that the highest rates of male-dominated fellowship directors were seen in adult reconstruction (100%), sports medicine (99%), and spine (96%) fellowships8. Increasing equitable gender representation among faculty leadership is a critical step in promoting a future generation of culturally competent, diverse orthopaedic surgeons3. However, the medical community should not solely rely on the already underrepresented faculty members to lead these initiatives. Instead, it would be more efficient and equitable for physicians belonging to majority groups to share in the responsibilities and support colleagues of diverse backgrounds2,3.
Comparison with other surgical subspecialties is helpful in placing these findings in the context of other literature. A study conducted by Behmer Hansen et al. found that neurosurgery fellowship choice also remains unequally distributed between genders14. Similarly, another study examined advanced gastrointestinal/minimally invasive surgery fellowship programs and found that women were underrepresented15. In otolaryngology between 2011 and 2019, one study found that women were selecting pediatric otolaryngology fellowship at higher frequencies than men, but no significant difference was seen in the other 9 studied fellowships16. Some studies hypothesized that significant contributing factors to these gender distributions are the underrepresentation of female program directors and faculty, sexual harassment, and interest in the discipline14,15. Successful recruitment and retention strategies of female trainees in these subspecialties should be further evaluated and implemented into orthopaedic subspecialties.
Intrinsic motivations of female orthopaedic surgeons for pursuing or not pursuing fellowship, including personal satisfaction and work-life balance, are other important factors to consider. Personal satisfaction and intellectual stimulation are top-ranked reasons for female orthopaedic surgeons to pursue fellowship9. Neurosurgery literature further reported obstacles to the retention of women within surgical training programs as intrapersonal (work-life balance and interested in discipline), interpersonal (relationship status and presence or absence of mentors), and organizational (length of training, family, and maternity leave policies)14. However, this investigation was not extended to neurosurgery fellowship. Additional research into how specific fellowships across surgical subspecialties support or appeal to individuals with these motivations would provide more insight into strategies for increased recruitment of gender-diverse trainees.
Strengths of this study include a well-powered, longitudinal comparison of ACGME-accredited orthopaedic residency and fellowship gender diversity data, which has been scarcely reported. These analyses contribute toward identifying disparities in gender diversity among orthopaedic surgery residents and fellows.
Our study is limited by a retrospective review of a database that is reliant on individuals' self-reporting of gender as binary, either male or female, which may not provide an option to accurately describe oneself17. For comparative analysis, it is implied that reasons for not self-reporting demographics would be similar across all fields analyzed. Perhaps, the largest limitation of our study is that only ACGME-accredited orthopaedic surgery and fellowship programs were analyzed. Many orthopaedic fellowships are not ACGME-accredited, and there has been a significant decrease in positions over the past decade (p < 0.001)12. We are thus unable to determine the destination of female graduates if they do not matriculate to an ACGME-accredited fellowship on completion of their orthopaedic residency. As a result, our analysis of this population is limited in sample size and may overstate the female representation in subspecialty fellowships. Finally, the database we used did not specify the contribution of osteopathic physicians after the ACGME/American Osteopathic Association merger under a Single Accreditation System18.
In summary, we found that although the percentage of female orthopaedic residents in ACGME-accredited programs increased significantly from 2007 to 2021, this has not translated to ACGME-accredited fellowship positions for women. Future research optimizing methods to improve the representation of females in orthopaedic surgery should be considered4.
Sources of Funding
None to report.
Footnotes
Investigation performed at The University of Arizona, Tucson, Arizona
There was no formal consent, informed consent, institutional review board approval, or ethical committee approval required for and/or applicable to this type of study because it did not require active human or animal participants.
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A626).
Contributor Information
Deborah Nelson, Email: djnelson@arizona.edu.
Nathan Sherman, Email: nsherman@ortho.arizona.edu.
Megan Tatusko, Email: tatuskom@ortho.arizona.edu.
Gregory DeSilva, Email: gdesilva@ortho.arizona.edu.
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