Introduction
The underrepresentation of minority groups in orthopedic surgery is a pressing issue in the United States. Despite the growth of minority populations, their representation in the field remains limited (Brotherton and Etzel 2019; Poon, Kiridly, Mutawakkil, et al. 2019; Adelani, Harrington, and Montgomery 2019) which is particularly concerning considering the importance of patient-physician racial concordance to improve patient care, increase patient involvement in decision-making, and improve patient satisfaction (Cooper-Patrick, Gallo, Gonzales, et al. 1999; Cooper et al. 2003; Saha, Arbelaez, and Cooper 2003; Kundhal and Kundhal 2003; Ramirez and Franklin 2019; Jetty et al. 2022). Thus, increasing race concordance through enhancing diversity in orthopaedic surgery should be a priority to optimize patient care.
It remains crucial to improve physician diversity in orthopedic surgery by increasing physicians considered underrepresented in medicine (URiM). URiM is defined by the Association of American Medical Colleges (AAMC) to describe racial and ethnic populations that are underrepresented in the medical profession relative to the general population (“Underrepresented in Medicine Definition,” n.d.). Previously underrepresented minority (URM) was the term used before the adoption of URiM in 2006. The definition of URiM is more open and adaptable to reflect the changing demographics of society. The lack of diversity in orthopedics extends beyond URiM students; women are also largely underrepresented in the specialty (Scerpella et al. 2022; Heest, Agel, and Samora 2021) which stems from the low number of URiM and women students applying to orthopedic residency (Poon, Nellans, Rothman, et al. 2019; Day, Lage, and Ahn 2010).
Reasons for this underrepresentation range from a perceived lack of diversity in the field, stereotypes of the field, and a lack of mentorship and exposure (Okike et al. 2020, 2019; Hill et al. 2013; Winfrey et al. 2022; Rahman et al. 2021). To address these challenges, early exposure to orthopedics during medical school, such as through structured courses, can increase interest in the field and provide valuable mentorship opportunities (Bernstein, Dicaprio, and Mehta 2004). Additionally, away rotations during the fourth year of medical school offer increased exposure, mentorship, and insights into different residency programs. Completing just one orthopedic rotation has been shown to improve URiM student perceptions of diversity and inclusion within the specialty (Rahman et al. 2021), potentially leading to increased interest in pursuing orthopedics.
Away rotations are considered essential for a strong residency application, especially in orthopedics (Andrews et al. 2016). The likelihood of matching at a program where students have rotated increased by approximately 50% (Camp, Sousa, Hanssen, et al. 2016; Higgins et al. 2016; Baldwin et al. 2009). Therefore, orthopedic surgery applicants typically incur higher total costs due to completing more away rotations compared to other specialties. However, the cost of away rotations can be a significant barrier. On average orthopedic surgery applicants spend approximately $2,850 on away rotations, compared to an overall average of $950 across all specialties (O’Donnell et al. 2017; Winterton, Ahn, and Bernstein 2016). The financial burden may deter URiM students from applying for orthopedics, further perpetuating the lack of diversity. To address this issue, many programs have implemented away rotation scholarships for URiM medical students. However, navigating the Visiting Student Learning Opportunities (VSLO) catalog and program-specific websites containing various program requirements, deadlines, and fees can be time-consuming and challenging. Additionally, some programs may not use VSLO, which students may overlook. Thus, the aim of this investigation was to provide a comprehensive review and detailed analysis of visiting rotation scholarships for URiM students in orthopedic residency programs.
Methods
Study Design
A comprehensive search was conducted by two authors (initials blinded for peer-review) by querying the Fellowship and Residency Electronic Interactive Database (FREIDA) of the American Medical Association (AMA) in June 2023 for all ACGME (Accreditation Council for Graduate Medical Education) accredited orthopedic surgery residency programs listed as participating in ERAS. Each institutional and program website, Google.com, Instagram.com, and Twitter.com were thoroughly searched for URiM scholarships, as defined by the individual program/institution, for visiting 3rd and 4th-year medical students. Multiple programs included women and LGBTQIA+ in their definition of URiM. Scholarships that were not directly provided by the orthopedic surgery department, or the institution at large, were excluded. If a scholarship could be used to rotate on specialties other than orthopaedic surgery, it was included in our study so long as orthopaedic surgery was one of the specialties available to rotate on. If the scholarship did not include orthopaedic surgery as an available specialty, it was not included in our study. Scholarships for opportunities that were not a formal away rotation, such as summer research programs, were also excluded.
Data Collection
Data extraction was performed by two research students and entered into a spreadsheet using Microsoft Excel version 16.63 (Microsoft Corp, Redmond WA). Data included the program name, post-graduate year-1 class size, program type (community, community with university affiliation, and university), regions as defined by the AAMC [East South Central (AL, KY, MS, TN), East North Central (IL, IN, MI, OH, WI), Mid-Atlantic (DE, DC, MD, NJ, NY, PA), Mountain (AZ, CO, ID, MT, NV, NM, UT, WY), New England (CT, ME, MA, NH, RI, VT), South Atlantic (FL, GA, NC, SC, VA, WV), Pacific (AK, CA, HI, OR, WA), West South Central (AR, LA, OK, TX), West North Central (IA, KS, MN, MO, NE, ND, SD), and Territories (PR, GU, VI, AS, MP)], number of scholarships offered, the monetary value of the scholarship, application deadline, availability to 3rd and/or 4th-year students, if a mentor/advisor is provided, if housing is provided, and required application documents (personal statement, letters of recommendation, curriculum vitae [CV], photographed headshot, transcript, United States Medical License Exam [USMLE] Step 1 score).
Statistical Analysis
Descriptive statistics were used to report demographic characteristics of each program. Categorical variables were presented as counts with percentages. Continuous variables were presented as mean ± standard deviation. Two-sided Student’s t-tests and chi-squared tests were used to assess differences between the number of scholarships offered by university-based programs compared to all other program types. The level of significance was established at a two-sided alpha level of p<0.05. All statistical analyses were performed utilizing R (version 4.2.2; R Foundation for Statistical Computing).
Results
Residency Program Demographics
A total of 202 programs were initially identified, of which, 67 (33.2%) programs offered a scholarship for URiM visiting medical students. Most programs defined eligibility of URiM status in a statement similar to the AAMC’s. Low socioeconomic status was accounted for in 8 programs (11.9%). Fifty-six programs were university-based (83.6%) and 5 were community-based, and 6 were community-based with university affiliation. Twenty-two (32.8%) institutions specified the number of scholarships being offered (mean, 5 ± 4.6; range, 1 – 20). Thirty-three (49.3%) programs offered orthopedic-specific scholarships, whereas 34 (50.7%) programs offered scholarships for multiple specialties including orthopedic surgery (Table 1).
Scholarship Characteristics
The average value per scholarship was $1,856.56 ± $706.60 (range, $500 - $4000). Four scholarships (6%) did not report the monetary value of the scholarship. The application deadline ranged from January 30th, 2023 to June 30th, 2024 of the academic year for the 46 (68.7%) programs that listed deadlines. Three (4.5%) programs reported a fee associated with the application, ranging from $15 to $200. Most programs (90%) catered only to 4th-year medical students; 7 (10.4%) programs allowed 3rd-year students to apply. One program offered a stipend solely for out-of-state students. Nineteen programs (28.4%) provided visiting students with an advisor or mentor. Two (3%) programs provided on-campus housing, whereas one (1.5%) provided off-campus housing (Table 1).
Application Requirements
As for application requirements, twenty-two programs (32.8%) required a letter of recommendation (range, 0 – 3) with 14 programs only requiring one. Fifty-three programs (79.1%) required an essay, with an average number of essays being 1 ± 0.7 (range, 0 - 3). Seven programs (10.4%) required a letter from a dean. Twenty-two programs (32.8%) required a CV, 19 programs (28.4%) required a transcript, 17 programs (25.4%) required a personal statement, 15 (22.4%) programs required a USMLE Step 1 score, and 7 programs (10.4%) of programs required a photo (Table 2).
Discussion
URiM students face many obstacles, including the financial burden of away rotations, which have become crucial for their careers. These rotations cost around $2,000 on average, posing a significant barrier, especially for URiM students from low socioeconomic backgrounds. To address this, orthopedic surgery residency programs have introduced diversity scholarships for visiting students, aiming to alleviate the financial burden and promote diversity. This investigation provides a comprehensive source of information on funded opportunities for URiM students seeking away rotations in orthopedic surgery. Our study revealed that in 2023 33.1% of graduate medical education orthopedic surgery programs currently offer URiM visiting student scholarships, indicating almost 1/3 of all GME programs offered some type of support for URiM visiting student scholarships in orthopedic programs. This is very encouraging that orthopedic residency programs understand the importance of promoting exposure to their programs and see the economic burden away rotations can place on students. Notably, of these programs that offered scholarships, most (83.6%) were university-based, and hopefully future efforts can be made to provide community-based program visiting scholarships enhancing this pipeline of URiM students, as the need for diversity in our communities is equally important. Interestingly, our study also uncovered that certain scholarship programs lacked clear guidelines and crucial information, such as stipend amounts or application requirements on their respective websites. Hopefully, our study can help encourage programs to provide the additional information needed and enhance their recruitment efforts for this type of support for URiM students. Our results demonstrated the majority of URiM visiting student scholarships were offered by university programs (83.6%). These findings suggest that university programs may demonstrate greater sensitivity or increased resources put toward diversity recruitment initiatives. The impact of these scholarships has been previously assessed in emergency medicine, where these programs have successfully increased diversity within their respective programs (Duong et al. 2021). Broadening scholarship opportunities will be crucial to increasing diversity in all residency training programs and practice settings. Community programs not only have important outreach opportunities but are critical for care concordance given many residents remain in or near the communities in which they train. From our results we report that the prevalence of these opportunities is mainly offered at university programs, therefore encouragement for expansion for a wider range of programs is important as we continue to move forward.
Beyond their practical benefits, offering URiM scholarships also serves as a testament to a program’s commitment to cultivating a diverse community of trainees. According to the 2017 National Resident Matching Program Applicant Survey, 37% of applicants across all specialties considered the cultural, racial, ethnic, and gender diversity of an institution as an important factor when selecting programs to apply (“Program NRM: Results of the 2017 NRMP Applicant Survey by Preferred Specialty and Applicant Type.,” n.d.). Recognizing that prospective applicants primarily rely on program websites to gather information; we utilized both program and institution websites to identify URiM scholarships. While these scholarships can serve as an indicator of a program’s dedication to diversity, it is essential to acknowledge that there is a limited number of URiM applicants competing for these positions. Therefore, it becomes imperative to implement additional initiatives earlier in a student’s medical school career, such as mentorship programs focusing on rotation choices, career trajectory, field of practice, and research, to maximize diversity efforts’ impact.
While the AAMC’s definition of URiM is based on racial and ethnic groups, many programs have their own, broader definitions for whom they deem are “Underrepresented in Medicine”. Of the programs we list, many include women and LGBTQIA+ in their definition, thus these students are eligible to apply regardless of race or ethnicity. Notably, some programs have even gone as far as to include students from a low socioeconomic status as eligible. This is a beneficial adjustment, as we see that across all races the students applying to and matriculating into medical schools are increasingly from the highest socioeconomic classes and that students interested in medicine from low socioeconomic backgrounds are less likely to apply to or be accepted into medical school (Nguyen et al. 2023; Shahriar, Puram, Miller, et al. 2022; Morrison and Cort 2014). By promoting socioeconomic diversity in orthopedics, these scholarships will help negate the effects of the current uniformity of socioeconomic status amongst physicians and medical students. These detrimental effects are illustrated in the negative emotions resident physicians report regarding care for impoverished patients, as well as the dissonance seen amongst resident physicians regarding actual versus self-perceived knowledge on topics relating to underserved populations (Price et al. 1988; Weissman, Betancourt, Campbell, et al. 2005; Wieland et al. 2010). Thus, by targeting scholarships to aid low socioeconomic students and provide attainable avenues of exposure to specialties, these scholarships will help promote socioeconomic diversity in medicine.
Program websites are a primary source of information for interested applicants, therefore they play an important role in promoting diversity and inclusion. One study found that residency applicants considered the accuracy of residency website information an important factor in their decisions to apply to the program, while another study noted how both applicants and orthopedic surgery residency programs could benefit from increasing recruitment content, educational content, and standardization of program websites (Gaeta et al. 2005; Sherman et al. 2020). Specifically, increasing content for topics related to diversity and inclusion is a notable area for improvement, as orthopedic residency programs rarely address these topics on their program websites (Mortman, Gu, Berger, et al. 2022). While the fact that most students utilize program websites when determining which programs to apply to has been established, there is little emphasis on the impact of including diversity and inclusion content in promoting URiM student applicants. Our results suggest that In the face of limited papers commenting on this, we speculate that, based on the existing relationship between website engagement and residency applications, this is yet another avenue for graduate medical education programs to improve diversity recruitment efforts by enhancing the accuracy and availability of diversity initiatives on their websites (Wei, Bernstein, Gu, et al. 2023).
Limitations
This study has limitations. First, it is imperative that applicants should be aware that additional fees, such as registration and processing fees, exist that were not discussed in this study. While every effort was made to ensure completion, website data may have been inherently missed or information not included in the website would have biased these results. Additionally, in the course of our analysis, we determined that certain data did not significantly impact our overall conclusions, and therefore, we have removed this data from our paper. Lastly, this study was a cross-sectional analysis, and scholarship opportunities will likely change over time. As the field of orthopedic surgery prioritizes diversity and inclusion, it becomes crucial to reassess the growth and effectiveness of these scholarships and their impact over time.
Conclusion
This study serves as a comprehensive analysis of URiM students visiting scholarship opportunities for away rotations in orthopedic surgery. While numerous URiM scholarships are available, continued reporting of these opportunities and tracking of their success in enhancing diversity in our field is needed. enhancing their availability is crucial to advance inclusivity in the field. Programs should collectively list their URiM scholarships on the AAMC website to increase awareness and encourage application for these resources which will hopefully positively impact our field of orthopaedic surgery.