Introduction
Orthopaedic surgery is one of the most competitive fields in medicine to successfully match. Orthopaedic surgery has the highest rate of specialty preference continuity from medical students when compared to other specialities (“2021 Report on Residents Executive Summary,” n.d.). In 2022, nearly 1,500 students applied to at least one of approximately 200 orthopaedic residency programs in which 875 matched into the specialty, resulting in a 63% match rate (“Residency Data & Reports,” n.d.). After training, orthopaedic physician retention in the state of residency has consistently been less in comparison to other specialties with, 43.2% practicing in the state in which they received training (“Residency Data & Reports,” n.d.).
Additionally, orthopaedic residency continues to fall behind other specialties in terms of gender and racial diversity (Poon et al. 2019; Vij et al. 2022). According to the 2018 AAOS Census, membership consisted of 5.8% female surgeons, 6.7% Asian, 2.2%Latino, and 1.9% Black (“Aaos Orthopaedic Surgeon Census,” n.d.). This diversity lessens further when broken down by state particularly in mid-western and southern states. Organizations, such as the Mid-America Orthopaedic Association (MAOA), strive to improve upon physician retention, diversification, and educational expansion in orthopaedics.
The MAOA is a regional society composed of 20 states formed to facilitate education and networking among its members. In the Mission Statement of the MAOA, it includes that the organization seeks to serve its members through an annual meeting educational program. This MAOA annual meeting has been held since its founding in 1982. A goal of MAOA is to encourage physician loyalty to the organization with its offerings to young surgeons, residents, and medical students. To accomplish this, there are multiple educational grant opportunities for research and for travel to the meeting for medical students, residents, and those new in practice surgeons. These grants were created to alleviate the financial burden that coincides with showcasing research at the annual meeting. The grants contribute funds towards travel, lodging, and meeting supplies such as posters and registration fees that can become barriers for participation in the conference. With it’s minimization of the financial burden, the grant permits access to educational enrichment, networking opportunities, and participation in advancements in orthopaedic surgery. All the while, it allows opportunity for attendees to develop skills presenting research in a low key environment. In addition, travelling fellowships are offered as an enriching educational experience for young surgeons in practice. The MAOA grant categories include either multipurpose resident grants, traveling fellowship grants, and education grants for medical students, residents, or new in practice physicians. The purpose of our study was to report on MAOA education grant winners, their demographics, current position and location, and membership status.
Materials and Methods
Grants have been awarded by the MAOA for senior residents and new in practice physicians (NIP) since 1999 and to medical students since 2019. These grants are specifically for persons located in one of the 20 MAOA states: Alabama, Arkansas, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee, Texas, or Wisconsin. To be qualified to apply for an education grant, the individual must have been a presenter of a podium or poster presentation at the annual meeting for that year. Senior residents/fellows education grants had to be in their final two years of residency to apply. For new in practice orthopedists, the grant must be received by individuals in their first or second year of practice. These grant winners were selected by the MAOA Education Committee.
The MAOA grant winners were obtained from the organization website (https://www.maoa.org/) and confirmed with staff. The list of grant recipients was obtained along with the following information: MAOA membership status, gender, grant winner year, and institution when the grant was received.
An internet search of social media and institution/hospital websites was conducted to determine current institution of residency or practice for all winners. Social media sites included Twitter, Instagram, or Facebook. For medical students, graduation status and subspecialty was determined. Each individual’s current institution was determined to be academic or private practice.
Results
There were 487 senior orthopaedic resident, 51 new in practice, and 44 medical student grants awarded from 1999 to 2021 (Table 1); however, 563 individuals won grants over this period with a total of 582 awards received due to 19 individuals winning multiple years (1 NIP, 12 residents and 6 medical students).
Of the 563 number of grant winners, 371 individuals (65.9%) remain in Mid-America territory representing multiple institutions and practices (Table 1). Majority of winners reside in Ohio and Illinois (Fig. 1). The majority of NIP (29 of 50; 58%) and senior resident (295 of 475; 62.1%) grant winners currently work in private practice (Table 2,3). The Mayo Clinic produced the greatest number of grant winners.
128 grant recipients are current members of MAOA. Membership status is low at 40% among new in practice orthopedists, 23% for senior residents, and 5% for medical students (Fig. 2). Membership of grantees to the MAOA has been increasing simultaneously with the increasing number of grants awarded (Fig. 3). 22 medical student winners matched into orthopaedics with nine who have not graduated yet. The majority of medical students who matched orthopaedics did so in MAOA territory (18 of 22; 81.8%) with only four students matching outside the region (Table 4). Additionally, of the nine students that have not yet graduated medical school, five are still known to be interested in pursuing a career in orthopaedics.
Gender breakdown of grant recipients was predominantly male (504 of 563, 89.5%) (Fig. 4). Female gender represented 6% of NIP physician, 10.1% of senior resident, and 21.1% of medical student grant winners (Fig. 4). The proportion of females receiving grants has increased since the inception of MAOA grants (Fig. 5). From 1999 to 2010, ten females were awarded to NIP and senior residents. From 2011 to 2021, 41 females were awarded to NIP and senior residents with eight female medical students awarded since 2019. Of the 128 grant winners who are MAOA members, Female membership was found to be 12.5%.
Discussion
Organizations such as the MAOA provide a unique opportunity to facilitate scholarly discussion, advancements in the field of orthopaedic practice, and networking to upcoming physicians. There are many benefits to joining orthopaedic organizations such as the MAOA which includes education. For residents and practicing physicians, it provides opportunities for professional development, networking, vendor exposure, and continuing medical education credits (Stoklosa 2022). Additionally, there is support for further research in the field of orthopaedics and affect clinical practice. For students, the annual meeting is a chance to present their work in a collegial environment and interact with residents and attendings, gaining insight into residency programs and practices. Organizations such as MAOA also allow for mentorship opportunities (Stoklosa 2022). Mentorship proves to be crucial in the influence of medical students’ pursuit in a career in orthopaedics (Meyer et al. 2021). This could play a role in our findings that 81.8% of individual’s who matched orthopaedics did so in the Mid America states.
Despite the benefits of the MAOA, membership status of award recipients remains low based on the available data, exposing a need for support and retention. The idea of orthopaedic associations being equipped to expand upon education, research, and advocacy is not new. The challenge of any association is to provide a solid network for actual influence that results in individuals wanting to participate. This requires organizations to change with the climate of the current healthcare system and ideals held by the people it serves. It demands that these associations remain relevant, nimble, and streamline their endeavors to make membership worthwhile (Nelson 2000).
One way to potentially promote membership is to get individuals involved early. The MAOA provides opportunities for medical student and resident presentations and scholarships, which incites a feeling of inclusion and support from the beginning. Having support from a large professional coalition perpetuates a sense of familiarity and comfort, which gives a purpose for an individual to pay it forward in the future. This concept is akin to medical device industry targeting surgical trainees to use certain implants because it has been shown to influence continued use in their future practice (Fury et al. 2019). The more exposure to the organization fosters loyalty between the parties. Additionally, if an individual feels involved/supported early on in their career or prior to their career even starting, it generates more of a positive personal attachment to the association.
An important consideration of increasing membership is the ability to fund the resources required to support a hopefully regional physician base. Based on our data, it appears that the as the number of grants given per year increases, a rise in memberships to the MAOA coincides. It could be theorized that individuals who won a grant in the past feel the desire to pay it forward to the next generation as the grants provided by the MAOA are funded by member donations. One goal of the MAOA is to make advancements that will ultimately improve the care and satisfaction of the Mid America populace, and it has been shown that many of the grant winners remained in Mid America territory (65.9%) (Fig. 3). Thus, it is imperative to improve membership and foster financial support, so there is continued ability to provide grants to a physician base that will be caring for the future Mid America populations. Just as residency location has an influence on the region of fellowship, grant funding appears to play a role in the influence of practice (Krueger et al. 2021).
The MAOA has provided a total of 582 grants; however, the gender diversity is sparse. Currently, the MAOA grant recipients have a vastly male demographic (89.5%). Female representation of grant recipients is certainly higher when comparing medical student winners in relation to residents and drastically compared to new in practice physicians. Trending female grant winners from 1999 to 2021, there has been an increase in the percentage of female grantees; however, female MAOA membership of grant recipients is low (12.5%). In general, female representation in orthopaedic residency and fellowship is 15.3% with a gradual, but slow increase of women in the field (Attia et al. 2021). Additionally, a recent study in 2021 displays similar findings regarding orthopaedic specialty societies having lower female representation, females in leadership roles, and fewer grants awarded (Attia et al. 2021). The MAOA is not an exception to this trend. However, the MAOA has made efforts to have female representation on the Board of Directors. Pertaining to orthopaedic organizations, it has been found that having women in leadership roles has a direct influence in the number of female members that the society has (Ramos et al. 2022). It is important to diversify orthopaedics because underrepresented groups, whether gender or racial, report improved patient satisfaction, comfort, and trust in the physician’s decision-making skills when working with someone from a similar culture (Reede 2003; Takeshita et al. 2020). Thus serving a diverse patient population, it would be appropriate for orthopaedics to have a physician base that reflects the times. Scholarships and funding female applicants in orthopaedics could postulate to be a method to increase female retention in the orthopaedic specialty (Vajapey, Cannada, and Samora 2019).
Our study has limitations. Our data does not have the self-identified gender of the individual. It is possible that some individuals are misgendered or identify as non-binary. Our study did not have information on grant winners preferred gender or age. We identified current practice location from website searches and it possible that these could be outdated. Additionally, not all individuals have a social media presence or keep their profiles on private settings; thus, it would impede on verifying/determining some of the study variables.
Conclusion
The MAOA fosters education, research, and patient care advancements for the Mid America regions. The meeting represents an opportunity to stay abreast of current clinical research impacting practice, interact with leaders in the field, develop relationships which can lead to opportunities for residency, fellowship and employment and a sense of belonging in the organization. The support of the region’s medical students, residents, and new in practice physicians through grants is an integral portion of the MAOA and are supported through member donations. The grants provide opportunities for young trainees and practitioners to attend a scientific meeting where we have demonstrated 59% publication rate of presentations (Loeffelholz, Piening, and Cannada 2018). While the majority of grant winners practice in Mid America states, many are not current members. Continued work is needed by the organization to improve the strength of the bond with grant winners. The organization has a major goal of improving diversification of the association and the field of orthopaedic surgery. Funding individuals through grants and scholarships proves to be one way to increase diversity. Including minority representation in director roles and other leadership positions within the organization could serve as another effort to promote inclusion. In all, there should be coordinated effort and strategic plans to encourage membership, diversification, and commitment to the organization.
Acknowledgements
The authors thank the Mid America Orthopaedic Association for their support of this study.