Letter to the Editor: Race, But Not Gender, Is Associated with Admissions into Orthopaedic Residency Programs

To the Editor,

We read the study by Poon et al. [5] with great interest and share the belief that the orthopaedic community and patients alike will benefit from efforts to eliminate structural inequalities in orthopaedic residency admissions practices. When analyzing academic factors, the authors point out that Alpha Omega Alpha (AOA) status and higher United States Medical Licensing Exam (USMLE) Step 1 score were most associated with orthopaedic residency admission. However, the selection process for AOA membership has been found to discriminate against racial minorities [2, 8], and there are still unexplained demographic differences in USMLE scores based on gender and race [6]. The authors suggest removing these metrics from candidates’ profiles before interviews in order to increase the admission probability of qualified minority applicants. However, as of the time of this article’s online publication, steps are already being taken to address these concerns.

As a result of the above-mentioned studies that demonstrated racial bias in the selection of students for AOA membership, several prestigious medical schools have chosen to end AOA or placed a moratorium on student nominations to evaluate the selection process. The medical schools at Harvard, Stanford, Yale, and the Mayo Clinic no longer have AOA chapters at their institutions [1]. Other schools such as Johns Hopkins University do not select students for AOA until after the residency match to avoid the influence of AOA membership on the admission process [4]. Over the last year, a number of other programs including University of California–San Francisco and Duke have followed suit by suspending elections to AOA, calling into question how AOA membership will affect admissions decisions in the coming years [3, 7].

Additionally, in early 2020, the decision was made to change USMLE Step 1 score reporting to a pass/fail outcome beginning in January 2022. Therefore, there likely will be changes in how applicant competitiveness is assessed. It is possible that the transition to pass/fail will help address racial disparities in residency admission by eliminating the use of “cut-off” scores that disproportionately exclude minority applicants [9]. However, given that residency programs are accustomed to having access to a metric that allows them to sort large numbers of applicants for interviews, USMLE Step 2 scores may simply replace USMLE Step 1 scores, which would result in a failure to address the underlying problem.

The lack of diversity in orthopaedic surgery is a complex, multifaceted issue. To achieve an inclusive environment requires change at every level, from addressing our own personal biases to making changes at an organizational level. It is difficult to anticipate how these large-scale changes will affect the results found in the paper by Poon and colleagues [5]. However, they present an opportunity to increase diversity within the orthopaedic surgery field and create a better, more equitable future.