Gender and Diversity Trends Among Hand Fellowship Training Programs in the United States

Abstract

Background:

Lack of diversity in healthcare teams can lead to poorer patient outcomes and quality of care. This study analyzed fellowship trainee demographics to examine current gender and racial diversity trends among hand surgery fellowship programs.

Methods:

American Medical Association Graduate Medical Education reports from 2007 to 2024 were queried to determine diversity trends among hand surgery fellowships. Trainees from 3 primary residency types were evaluated: plastic, orthopedic, and general surgery. Microsoft Excel and IBM SPSS were used to trend and analyze the data using χ² analysis, Fisher–Freeman–Halton exact tests, and Cochran–Mantel–Haenszel tests.

Results:

Hand fellowship programs increased 42% from 2007 to 2024. Female trainees rose to 38% in 2024 but remained significantly fewer than males (P < 0.01). Gender distribution was similar across orthopedic and plastic programs (P = 0.06). Programs had significantly smaller percentages of Asian (2007 = 12.9%, 2024 = 17.8%; P < 0.01), Pacific Islander (2007 = 0%, 2024 = 0%; P < 0.01), African American (2007 = 3.1%, 2024 = 5.2%; P < 0.01), American Indian (2007 = 0.0%, 2024 = 0.0%; P < 0.01), and Hispanic trainees (2007 = 5.3%, 2024 = 0.6%; P < 0.01) compared with White trainees (2007 = 68.9%, 2024 = 64.3%). Osteopathic (2007 = 8.3%, 2024 = 8.9%) and international medical graduate trainees (2007 = 13.6%, 2024 = 1.3%) also remained low.

Conclusions:

Although hand fellowship programs have improved female representation, trainees underrepresented in medicine remain low.

Takeaways

Question: How has gender, racial, and ethnic diversity in hand surgery fellowships changed since 2007?

Findings: Based on American Medical Association Graduate Medical Education data from 2007 to 2024, female trainees increased but were still significantly outnumbered by their male counterparts. Underrepresented minority trainee representation declined. Gender and underrepresented in medicine distributions were similar across orthopedic and plastic surgery fellowship subspecialties.

Meaning: Gender diversity has improved, whereas racial and ethnic diversity remains limited, highlighting the need for targeted strategies to better recruit and retain underrepresented trainees in hand surgery fellowships.

INTRODUCTION

During the past several decades, there has been rapid growth in the diversity of the US population, with more than a 15% increase in the percentage of racial and ethnic minorities from 2000 to 2021.^1,2 There has also been significant growth in diversity among applicants entering medical schools, with women now comprising over half of US medical students.³ Research has shown that the growth in diversity among surgical training programs has not matched the pace of the US population.⁴ Furthermore, data analysis of the Association of American Medical Colleges has shown that although female representation in medicine and general surgical training programs has increased, only a small percentage of underrepresented minorities attend medical school, and minority representation in surgical training programs is limited.^5–7 These disparities are reflected in surgical subspecialties as well, with women and underrepresented minorities in medicine (URM) remaining marginalized in fields such as orthopedic, plastic, and hand surgery.^6,8–11 However, plastic surgery does have one of the highest growth rates of female residents among surgical subspecialties, indicating that gender equality is gaining traction.¹² The importance of diversity in healthcare teams has been well established, with previous studies demonstrating that a lack of diversity can contribute to poorer patient outcomes and quality of care.^13–15 Consequently, there has been an increasing emphasis on developing initiatives to improve diversity in surgery programs. Within the field of hand surgery, many organizations have similarly begun taking steps toward greater inclusion and representation of women and URM over the past several years; however, there is still limited data on diversity among hand surgery fellowship programs. A critical part of creating and maintaining a culture of diversity is through ongoing assessment of our efforts to track progress and identify areas in need of improvement. The purpose of our study was to review trends in sex, race, ethnicity, and educational background of physicians training in hand surgery fellowships across subspecialties. We believe this information will provide fellowship programs with insight into the current state of diversity within hand surgery and build a base for open discussion on how to improve racial, ethnic, and gender diversity among qualified applicants choosing to pursue this area of specialty training.

METHODS

Data Collection

Graduate Medical Education (GME) reports from the American Medical Association (AMA) were queried, using publications from the Journal of the American Medical Association Network Open. Physician demographics among trainees in hand surgery were analyzed for each program annually from 2007 to 2024. We identified sex and URM status for each particular year of the hand fellowship data. URM status was defined as Black or African American (AA), Hispanic/Latino/Spanish, American Indian or Alaskan Native, Native Hawaiian/other Pacific Islander, or other race/ethnicity by the AMA. Hand surgery fellows were from orthopedic surgery (OS), plastic and reconstructive surgery (PS), or general surgery (GS) specialties. Data from each program identified the type of fellowship primary specialty (OS, PS, GS); sex; URM status; and educational background, including doctor of allopathic medicine (MD), doctor of osteopathic medicine (DO), and international medical graduate (IMG) status for their trainees. These data were subsequently analyzed to evaluate trends among sex, URM status, and educational background, allowing comparison among the 3 fellowship primary specialty groups.

Statistical Analysis

Statistical analysis was performed using 2 software programs: Microsoft Excel and IBM SPSS Version 27 to compare trends in the hand surgery fellowship workforce. Further analysis was performed to evaluate differences and trends over time in sex, URM, and IMG status for all fellowship programs within each surgical specialty field. IBM SPSS was used to perform χ² analysis and Fisher–Freeman–Halton exact tests for the same data points. Cochran–Mantel–Haenszel tests were used to examine across years when dispersion allowed. Pearson correlation coefficients (r) were calculated to describe the strength and direction of temporal trends in demographic proportions. Statistical significance was defined as a P value of less than 0.05.

RESULTS

From 2007 to 2024, hand surgery fellowship programs increased 42% (69 to 98), with a corresponding increase in fellows by 19% (132–157). The majority of new programs (22 out of 29) were orthopedic-based hand surgery training programs, followed by plastic surgery (6) and 1 new GS program in 2021. The number of orthopedic and plastic surgery fellows increased by a total of 31 new positions in 2024, whereas GS hand fellows declined from 8 to 2, despite the additional GS program.

When comparing gender status among fellowship trainees, there was a significantly higher percentage of male trainees compared with female trainees (P < 0.01). In 2007, 82.4% (n = 108) of the fellows were men and 18.3% (n = 24) were women, compared with 63.2% (n = 98) men and 38.1% (n = 59) women in 2024 (Fig. 1). Overall, female representation increased 108% during the study period, with an increase of nearly 10 percentage points between 2023 and 2024. (See table, Supplemental Digital Content 1, which displays the percentage of female hand surgery trainees listed by primary specialty from 2007 to 2024, https://links.lww.com/PRSGO/E846.) PS hand programs increased from 2 female trainees to 11 (a greater than 300% increase in the percentage of female trainees), and OS programs increased female representation from 21 to 47 trainees (an 81% increase in the percentage of female trainees). There was no significant difference between the average percentage of female trainees across years between OS and PS programs (P = 0.06), whereas GS had a significantly higher proportion of women than OS programs (P = 0.03) (Supplemental Digital Content 1, https://links.lww.com/PRSGO/E846).

Fig. 1.

Distribution of female hand surgery fellows by specialty training program from 2007 to 2024.

Comparing race and ethnic diversity in hand fellowship programs from 2007 to 2024, White trainees significantly outnumbered Asian (P < 0.01), Pacific Islander (P < 0.01), Black/AA (P < 0.01), American Indian (P < 0.01), and Hispanic fellows (P < 0.01). Although White trainees remained the largest group, their proportion did decrease slightly from 69% to 64% (Fig. 2). Asian fellows were the second largest group, followed by AA and Hispanic fellows in 2024. From 2007 to 2024, the percentage of Hispanic trainees declined from 5.3% to 0.64%. AA representation was 5.2% in 2024, compared with 3.1% in 2007, though it showed high variability with an overall weak negative trend (r = −0.31). Pacific Islander/Native Hawaiian and American Indian/Native American fellows remained small in number, comprising at most 0.8% and 1.4%, respectively. Trainees identifying as other/unknown spiked briefly in 2020–2021 (9–43), but decreased to n = 9 (5.7%) by 2024, with high year-to-year variability. Asian trainees were the only racial/ethnic group to increase overall during this period from 12.8% to 17.8%, though their numbers were also variable (Fig. 2). There were differences noted in URM distribution when compared between subspecialties (Fig. 3). OS had a significantly larger proportion of White trainees than PS (P = 0.048) and Pacific Islander trainees than both PS and GS (P = 0.01). Other URM distributions were similar across OS, PS, and GS programs (P > 0.05).

Fig. 2.

Distribution of race/ethnic representation in hand surgery training programs from 2007 to 2024.

Fig. 3.

Distribution of racial/ethnic minority fellows in hand surgery training programs from 2007 to 2024 by subspecialty. Each panel shows the proportion of trainees in OS, plastic surgery, and GS from Asian (A), Hispanic (B), Black or AA (C), and other or unknown race/ethnicity minorities (D). Y axes are standardized to allow for visual comparison.

Significant differences were also identified between trainees based on the type of medical school (MD or DO) and the location of the medical school they attended (United States or international). Hand surgery fellows were overwhelmingly MD graduates (P < 0.01), with DO representation remaining similar between 2007 and 2024 at 8.3% (n = 11) and 8.9% (n = 14), respectively, and no strong trend over time (r = −0.04) (Fig. 4). IMGs showed a declining trend from 13.6% (n = 18) to 1.3% (n = 2), a 91% decrease in the percentage of IMG trainees from 2007 to 2024 (Fig. 5). OS and GS programs had more DO fellows than PS programs (OS, P < 0.01; GS, P = 0.02), whereas PS and GS programs had more international graduates compared with OS programs (PS, P = 0.02; GS, P < 0.01). (See table, Supplemental Digital Content 2, which displays the percentage of hand surgery fellows with osteopathic medical school training listed by primary specialty from 2007 to 2024, https://links.lww.com/PRSGO/E847.) (See table, Supplemental Digital Content 3, which displays the percentage of hand surgery fellows with international medical school training listed by primary specialty from 2007 to 2024, https://links.lww.com/PRSGO/E848.)

Fig. 4.

Distribution of US osteopathic medical degrees among hand surgery fellows from 2007 to 2024 by fellowship subspecialty.

Fig. 5.

Distribution of IMGs among hand surgery fellows from 2007 to 2024 by fellowship subspecialty.

DISCUSSION

This study evaluated sex, racial, and educational diversity trends in hand surgery fellowships from 2007 to 2024. We found a 108% increase in female fellows, though men continue to outnumber women significantly. These findings align with prior database studies and reflect broader increases in women entering medical school and residency.^3,6,16–18 Although surgical fields have historically lagged in gender parity, plastic surgery and GS now approach equal representation (50.2% and 48.1%, respectively) of female residents, whereas OS remains low at 22.4%.⁶ Notably, female representation in both orthopedic and plastic surgery hand fellowships now meets or exceeds their respective residency rates, highlighting successful diversity initiatives. However, female authorship and conference participation in plastic surgery, while increasing, have not matched trainee growth.^19–22 Disparities persist in publications even at similar professional levels and in hand/extremity abstract presentations and senior authorship.^23,24

Gender diversity gaps are additionally seen in hand surgery leadership, with women comprising only 15% of faculty and 13% of fellowship directors, and being less likely than men to hold full professorships despite their increasing presence.^25,26 Underrepresentation of women in leadership positions parallels feeder surgical specialties, where 10% of plastic surgery, 15% of GS, and 4.1% of OS chairs are women.^27–29 Female residents were less interested in pursuing academic practices than their male counterparts, which may partially explain these disparities.³⁰ Although there was no significant difference in average female representation across fellowship types during our study period, orthopedic hand fellowships (35%) continue to lag behind plastic surgery hand fellowships (55%), which successfully achieved gender parity in 2024. However, the orthopedic hand fellowship percentage exceeding active orthopedic residency rates suggests successful fellowship-level recruitment, while highlighting potential barriers at the residency application level that may prevent women from applying to or being accepted into orthopedic programs.

Racial disparities remain more pronounced. White fellows continue to represent the majority, with significantly fewer Asian, AA, Hispanic, Pacific Islander, and Native American fellows. Trends showed declining Hispanic representation and varied but low AA representation, with no differences between subspecialties for these groups. There were significant differences in proportions of other racial/ethnic groups between the subspecialties, though the very small GS cohort (n = 2 in 2024) in combination with small racial cohorts likely exaggerates some of these results. Our findings are not reflected in broader surgical residency demographics, as recent data show that GS trainees now include 18% Asian, 11% Hispanic, and 6% Black residents.⁶ Our data more closely mirror the current, less diverse orthopedic and plastic surgery active residency distributions, where Hispanic trainees represent 7.6% and 9.6%, respectively, and Black trainees represent 5.8% and 4.1%, respectively.⁶ In contrast to our findings, Fones et al¹⁷ reported increasing URM representation from 2011 to 2022 using Accreditation Council for Graduate Medical Education data; however, with the inclusion of 2007–2010 and 2023–2024, our analysis shows high variability. Fellows reporting “other/unknown race/ethnicity” declined sharply by 2011 before rebounding and declining again by 2024, suggesting that variability in reporting complicates long-term trend interpretation and underscores the need for continued monitoring.

However, these URM comparisons to overall residency data may not fully capture the diversity of the actual applicant pool. A more appropriate comparison is to the graduating cohorts from feeder specialties eligible to apply for a hand fellowship. For example, only 4.1% of 2018 matched integrated plastic surgery residents were URM, lower than our reported 15% among 2024 plastic surgery hand fellows, although methodological limitations in available match data complicate direct comparisons.³¹ This suggests a more diverse group of applicants successfully matched into plastic hand surgery fellowships, potentially indicating that fellowship-level initiatives have been successful while residencies need continued improvement. This is demonstrated by studies finding no improvement in plastic surgery URM representation between 2015 and 2020, with declining Hispanic trainees, compared with 2010–2014.³² Similarly, although OS URM applicants increased from 2011 to 2021, the adjusted odds ratio for matching as a URM was significantly lower than non-URM applicants.³³ These findings suggest that limited URM representation in hand fellowships largely reflects the severely constrained pipeline from medical school through residency training in the feeder specialties themselves.

We found that diversity in educational background by IMG status also declined by 91%, whereas osteopathic trainees were more variable year-to-year. DO representation was higher in GS and OS programs, whereas IMG representation was higher in plastic surgery than in OS programs. These findings reflect the scarcity of DO and IMG residents in orthopedic and plastic surgery. In 2024, only 0.9% of plastic surgery residents graduated from osteopathic programs, and 1.5% of orthopedic residents were IMGs. This is in contrast to overall medical training, where DO and IMG participation has risen (19.2% and 21.7% in 2024).⁶ DO and IMG match rates have also increased in GS after the Accreditation Council for Graduate Medical Education merger in 2019, but not in surgical subspecialties.^34,35 The declining fellowship diversity despite broader medical inclusion further suggests barriers within surgical subspecialty residencies themselves. Limited exposure to surgical subspecialties in DO and international programs, combined with increasingly competitive requirements for test scores and research productivity, may disproportionately disadvantage these groups.³⁶ Early exposure to subspecialty procedures is critical, as operative experience is the primary driver of initial interest in plastic surgery, suggesting that DO and IMG students with limited hand surgery exposure may not develop early interest in the field.³⁷

Several factors may contribute to persistent disparities in hand surgery and feeder specialties. Mentorship quality and availability are critical. In 1 study, 84% of women valued female mentorship, yet only 23% had such mentors in residency, and 36% reported negative mentorship experiences, often citing lack of support and self-promotion.³⁸ Similarly, female plastic surgery trainees frequently report that lack of a same-sex mentor is a barrier to professional development.³⁹ Early mentorship has been linked to career advancement, increased research productivity, and reduced burnout.^40–42 Yet only 19% of fellowship leaders are women, and 14% are URM, limiting mentorship pools.⁴³ With pass–fail curricula increasing dependence on mentorship for opportunities, demographically similar mentors are valuable for navigating unique challenges related to sex, race, or background.⁴⁴ Studies have found that both students and mentors are often limited by a lack of time and exposure to mentorship opportunities; structured mentorship programs can foster relationships between diverse mentors and trainees.^39,45 Representation in wellness programs also improves advocacy for supports such as prenatal care, childcare, and parental stress, which may disproportionately affect underrepresented groups.⁴⁶ Continuing mentorship through conference attendance and peer support networks helps retain diverse early-career surgeons and reduce burnout.⁴⁷

Minority trainees may also be deterred by microaggressions. Female and underrepresented minority orthopedic surgeons reported more frequent experiences of being perceived as less intelligent, dismissed, or treated inferiorly than their White male peers.⁴⁸ Bourne et al⁴³ found that 95% of women and 82% of URM hand surgeons reported experiencing bias in the workplace, with similar rates across plastic surgery training and extending to postgraduate year level and sexual orientation.⁴⁹ Such perceptions may discourage interest in White, male-dominated specialties.⁴³ Bias may also affect evaluations, as Bradford et al⁵⁰ found that recommendation letters for AA hand surgery applicants contained less agentic and communal language, which may be read as indicating a weaker candidate. Similar findings exist across sexes in other surgical specialties, including plastic surgery.^51–54 This suggests that implicit biases, even early in the residency application process, could influence matriculation into hand surgery if trainees are unable to match into the competitive feeder programs. Workplace discrimination contributes to burnout and emotional exhaustion, which affects nearly one-third of plastic surgeons.⁵⁵ Addressing overt and systemic discriminatory practices and providing individualized mentorship at all training levels is essential for attracting and retaining a diverse hand surgery workforce.⁵⁶

Despite these challenges, targeted initiatives within hand surgery show promise. The American Society for Surgery of the Hand (ASSH) launched diversity efforts in 2021, specifically making calls to emphasize female authorship at annual meetings. Female abstract authorship rose significantly from 20% in 2020 to 26% in 2021, with fewer male-only panels.⁵⁷ In 2023, when all 3 ASSH annual meeting leaders were women, the meeting had significantly higher percentages of female speakers, moderators, and panels with female representation compared with the prior year, which was led entirely by men.⁵⁸ When compared with other orthopedic conferences, the American Association for Hand Surgery had the most balanced distribution of female attendees and speakers.⁵⁹ Other studies have shown increasing female authorship and leadership in recent years.^60,61 These results highlight that directed organizational efforts can improve the visibility and participation of underrepresented groups, signaling inclusivity to future trainees.

Although we believe our study sheds light on the trends of diversity among hand surgery fellowship training programs, it is also important to note several limitations. Our data from the AMA are self-reported with potential for response bias, which we were able to minimize but not eliminate. Although recent reports had a 94% program response rate, they captured 98% of trainees, and our 18-year span, which focused on objective demographic categories, helps to identify consistent trends despite year-to-year variability.⁶ Much of the race/ethnicity analysis was limited by low annual numbers. Due to the lack of dispersion in our data, it was not feasible to perform χ² analysis and Fisher–Freeman–Halton exact tests (ie, when expected counts are less than 5), as certain races/ethnicities had consistently 0 counts in multiple years. Similarly, the small cohort of GS fellows likely exaggerates some of the significant subspecialty differences. Although we compared fellowship diversity to overall residency demographics, an ideal analysis would compare it to the specific graduating cohort eligible to apply each year. Future studies using publicly available match demographics from 2022 onward will provide greater insight into proximal versus distal diversity barriers. Finally, our dataset did not allow for regional analysis, which could identify geographic variations in diversity recruitment and highlight successful programs as models for other regions.

A diverse physician workforce is essential, as it improves minority patient access, patient communication, and cultural competency, resulting in improved health outcomes and patient satisfaction.^{13–15,62,63} There is evidence that progress has been made toward gender inclusion within hand surgery fellowships, leadership, and professional meetings, but racial/ethnic and educational diversity remain stagnant or declining. Systemic barriers such as lack of mentorship, limited exposure, competitive requirements, and perceived bias should be assessed. Fellowship programs can contribute by improving mentorship opportunities, promoting minority leadership participation at national meetings, and evaluating institutional culture for inclusivity. Further monitoring of the long-term impacts of ongoing interventions will be important to ensure progress in diversity in the field of hand surgery.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. This project was supported, in part, by the National Center for Advancing Translational Sciences of the National Institutes of Health (grant no. UL1 TR001450). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.