Introduction
Orthopaedic surgery is one of the least diverse fields in medicine. While Van Heest et al. showed that there was an increase in the number of female orthopaedic surgery residents throughout a 15-year period in the United States (Van Heest, Agel, and Samora 2021), orthopaedic surgery still lags behind other historically male dominated fields with regards to percentage increases in female presence (Chambers et al. 2018). Currently, the majority of the research involves orthopaedic surgical residents, and there is a paucity of literature investigating the demographics of current orthopaedic surgery faculty members in the United States. Additionally, there is a sparsity of literature regarding degrees held by the orthopaedic surgery faculty.
The Accreditation Council for Graduate Medical Education (ACGME)- American Osteopathic Association (AOA) merger was first introduced in 2015 with the idea that all accredited residency programs would now be under the jurisdiction of one accrediting system instead of two. This merger allows for a uniform framework for training and quality care in the United States. Cumming et al (Cummings 2021). demonstrated that almost one quarter of surgical specialty AOA-accredited programs did not become ACGME certified, resulting in a loss of over 40 programs, including some orthopaedic residency programs. With this merger now complete, there is an increase in residency program faculty as well as a potential increase in faculty diversity.
The purpose of this study was to determine the demographics and education training of all current orthopaedic surgery residency program faculty members. We hypothesized that there would be a sex discrepancy among orthopaedic surgery faculty, with fewer females than males, and that there would be fewer DO (Doctor of Osteopathic Medicine) than MD (Medical Doctor) orthopaedic surgeons in academic medicine.
Methods
In January 2021, all ACGME accredited orthopaedic surgery residency programs were reviewed using the Fellowship and Residency Electronic Interactive Database (FREIDA). The publicly accessible websites of the accredited programs were individually searched to obtain information about the programs’ faculty from January to April 2021. Faculty information gathered included medical degrees earned, sex, subspecialty, academic role, and administrative titles held. The following specific academic and/or administrative roles were evaluated: "Chair’, “Vice Chair”, “Medical Director”, “Residency Program Director”, “Assistant Program Director”, “Director/Chief of Subspecialty”, “Fellowship Director”, “Professor”, “Professor Emeritus”, “Assistant Professor”, “Adjunct Professor”, “Associate Professor”, and “Instructor”. Photographs of faculty members provided on program websites as well as pronouns (when listed) were used to categorize faculty sex. If photographs were not provided, an external online search of faculty names was performed to evaluate sex.
During this same time frame, additional internet searches were occasionally conducted to determine the faculty’s residency if not provided on the program’s website or in case of broken Uniform Resource Locator (URL) links. Residency programs were assigned a region based on the Agricultural Research Service’s classification of regions in the United States, with an added sixth region to include international residency training. The 5 regions included are as follows: 1 – Northeast, 2 – Southeast, 3 – Midwest, 4 – Plains, 5 – Pacific West. Each faculty’s employment residency program was compared to the residency program where they trained to determine if they remained in the same institution, same state, and/or same region.
Results were categorized into 3 comparative groups: allopathic and osteopathic residency programs, surgeons with an MD or DO degree, and male versus female orthopaedic surgeons. Groups were further broken down into categorical specialty training, geographic location, academic role held, and any associated administrative titles carried by the orthopaedic surgeon affiliated with the residency program. The surgical specialties that were evaluated were adult reconstruction, trauma, sports medicine, spine, pediatrics, hand/upper extremity, oncology, foot and ankle, general, and faculty that were trained in more than one subspecialty. The collected data was analyzed using Microsoft Excel (2013/2016) and SPSS software, version 25. Chi squared analysis was used for dichotomous variables and analysis of variance (ANOVA) was utilized for continuous variables. P-values less than 0.05 were deemed statistically significant.
Results
The FREIDA search identified 199 accredited orthopaedic surgery residency programs. Of the 199 programs, 153 (76.8%) were traditionally allopathic, 38 (19.1%) osteopathic, and 8 military (4%). Military programs were excluded from analysis due to the lack of publicly available faculty data. Of the remaining 191 programs, websites for 2 programs did not provide faculty information. The remaining 189 programs’ websites provided information for 4,325 faculty members.
3,893 (90%) faculty members were male and 432 (10%) were female. 4,033 (93.3%) held Medical Doctor (MD) degrees and 291 (6.7%) held Doctor of Osteopathy (DO) degrees (Table 1). Subspecialties, academic roles, administrative titles held, geographic location of the institution, and residencies attended are detailed further in Table 1.
Traditional allopathic orthopaedic residency programs (TAPs) and traditional osteopathic accredited residency programs (TOPs) were compared (Table 2). There were more MDs (3,728, 97.5%) in both allopathic and osteopathic programs than DOs (305, 61%) (p<0.001). There were more male faculty (3,415, 89.3% MD and 478, 95.6% DO) and general orthopaedic surgeons (142, 3.7% MD and 66, 13.2% DO) in TOPs than TAPs (p<0.001 and p<0.001, respectively). TAPs had more pediatric orthopaedic surgeons (530, 13.9%), p=0.009), and hand and upper extremity surgeons (702, 18.4% vs 60, 12.0%) (p<0.001). Univariate analysis revealed no difference in program region or faculty’s residency region between traditional allopathic and osteopathic residency programs (p=0.545 and p=0.198, respectively). Not enough information was provided by TOPs to determine significance between academic roles held across program type. Only 8% (3/38) of academic roles were reported for TOPs, whereas 71.5% (109/153) of TAPs had information regarding academic role on the programs’ websites (p<0.001).
When comparing MD orthopaedic surgeons and DO orthopaedic surgeons (Table 3), we found that there were more male and general orthopaedic DOs than MDs (95.6% vs 89.3%, p<0.001, and 14.8% vs 4.1%, p<0.001, respectively), and more hand and upper extremity and oncology MDs than DOs (18.2% vs. 10%, p<0.001, and 4.6% and 0.7%, p=0.001, respectively). More DOs were listed as only “faculty” on the websites (81.8% vs 75.3%, p=0.013); however, DOs also comprised a larger percentage of assistant program directors and program directors (4.1% vs 2.0%, p=0.018 and 7.9% vs 3.9%, p=0.001, respectively). More MDs were listed as Director/Chief of their respective divisions and as Chair of Orthopaedics (12.3% vs 5.5%, p<0.001 and 3.6% vs 0.7%, p=0.008, respectively) than DO faculty. Univariate analysis revealed no difference in program region or faculty’s residency region between MDs and DOs (p=0.886, p=0.227, respectively). Not enough information was provided about DOs to determine significance between academic roles held across program type. Only 19.6% (7) of academic roles were reported for DOs, whereas 67.3% (112) of MDs had information regarding academic role on the programs’ websites (p<0.001). It needs to be taken into account that information provided on academic program websites may be outdates or inaccurate.
Table 4 summarizes findings between male and female orthopaedic surgeons. More male faculty subspecialized in adult reconstruction (616, 15.8%, p<0.001), trauma (489, 12.6%, p=0.033), sports medicine (719, 18.5%, p=0.007), and spine (471, 12.1%, p<0.001). A higher relative percentage of female faculty subspecialized in pediatrics (p<0.001), hand and upper extremity (p=0.001), and oncology (p<0.001). No difference was found between sexes and subspecializing in foot and ankle. More female faculty were listed as “only faculty” (79.9% vs. 75.3%, p=0.034) and more males were listed as Chair of Orthopaedics and as Fellowship Directors (3.7% vs. 1.2%, p=0.006 and 2.9% vs. 1.2%, p=0.039, respectively). More female faculty were listed as assistant professors than males (43.5% vs 27.2%, p<0.001) and more male faculty were listed as professors than females (15.9% vs 9.5%, p<0.001). Male faculty remained in the same state and same region as their residency training more than female faculty, but no difference existed regarding remaining in the same institution between sexes (p=0.011, p=0.026, and p=0.205, respectively). Finally, there was no difference between sexes with regards to orthopaedic residency training regions.
Discussion
To our knowledge, this is the first study to evaluate academic orthopaedic faculty by degree. We found that there are very few DO orthopaedic faculty compared to their MD counterparts (4,033 MDs vs. 291 DOs). Additionally, there are more MD faculty in American Osteopathic Association (AOA) accredited programs than DOs. Additionally, MDs have a higher tendency to be subspecialized, and while most DOs are also subspecialized, they appear to be more inclined to pursue general orthopaedics compared to their MD counterparts. One possible explanation is that many DO residency training programs are not affiliated with academic institutions and are in more rural environments; therefore, the exposure to and need for general orthopedists is higher. Additionally, we found a paucity of female orthopaedic surgeons in leadership roles.
One specific trend that was noted in this study is the limited academic role listing in AOA programs compared to ACGME-accredited programs. Fewer DO orthopaedic surgeons were listed as assistant, associate, and full professors, indicating a less prevalent role in academic medicine. This may be in part be because DO orthopaedic surgeons and residency programs have more affiliations with community-based hospitals than academic institutions.
Additionally, there were more MD orthopaedic surgeons listed as “Chair” or “Directors”; whereas more DOs held positions such as Assistant Program Director and Program Director. We found that there was a profound lack of accurate role description for the traditional osteopathic programs. TOPs, when academic roles were included on their program information, tended to record positions including Program Director or Assistant Program Director. Further research could focus on determining whether this is due to a lack of complete information or because there is a true discrepancy of academic roles between DO and MD orthopaedic surgeons affiliated with ACGME accredited orthopaedic residency programs.
Shah et al. demonstrated an increase in female orthopaedic faculty from 8.5% to 17.9% from 1997 to 2017 in traditional allopathic programs (Shah et al. 2020). Our study showed only 10% of orthopaedic faculty to be female, which is consistent with Nguyen et al. demonstrating only 9% of residency faculty being female in 2007 (Nguyen et al. 2010). Shah et al. also demonstrated that in 2017, 11.7% of senior orthopaedic faculty were women and 19.8% were junior faculty including: 9% professors, 14.5% associate professors, and 39.7% instructors (Shah et al. 2020). Our study demonstrated that female orthopaedic surgeons comprised 15.1% of all assistant professors. Out of all female faculty positions, assistant professor was the most common (43.5%). We also found that females comprised 11.9% of all associate professors and only 6.2% of all professors. When it came to sex comparisons in orthopaedic faculty administrative titles, there were more males in the positions of “Fellowship Director” (111, 2.9%) and “Chair” (145, 3.7% compared to female faculty (5, 1.2% both categories, respectively).
In 2020, Chen et al. demonstrated that 5.4% of shoulder and elbow fellowship program faculty were women (Chen et al. 2020). Our study revealed a much higher percentage of female faculty in upper extremity. This could be confounded by the fact that we included not only shoulder and elbow surgeons, but also hand surgeons in our upper extremity category. This was mainly because there was a discrepancy in fellowship categorization across faculty information. In contrast to Shah et al. and our own study, Chen et al. demonstrated no significant effect of sex on attainment of professor rank or leadership roles (Chen et al. 2020).
Lastly, the AOA-ACGME merger has now been in full effect and will hopefully instill a larger emphasis on academic values across all accredited residency programs, thus allowing DO orthopaedic surgeons to pursue higher academic roles and administrative titles, if desired.
Cummings et al. demonstrated that 26% of surgical specialty osteopathic accredited programs either withdrew or voluntarily withdrew from potential ACGME merging (Cummings 2021). This resulted in a loss of 41 surgical programs during a time of rapid growth for osteopathic medical schools. This study also anticipated a slowed progression of transition of DO’s integration into already previous ACGME established residency programs.
There are several limitations to this study. Current information available on program websites may be outdated or inaccurate, leading to skewed results. Additionally, there may be data missing, including academic roles and administrative titles, which was frequently absent on websites for AOA-accredited programs. Finally, military programs were excluded from the study due to lack of publicly available program data, which may affect the generalizability of this study’s results to all programs. Given that this was a cross-sectional analysis, we are only able to report on currently available information without trends.
Conclusion
The current faculty of orthopaedic surgery residency programs is heavily male dominated, holding higher academic roles and administrative titles than women. There is also a high prevalence of MDs with higher academic roles and administrative titles than DOs. As we anticipated there were a larger number of males and MD’s holding academic and leadership roles in academic orthopaedic surgery residency programs.