What Program Characteristics Are Associated with Resident Racial Diversity in Orthopaedic Surgery? An Analysis of Association of American Medical Colleges Data

The Perception of Residency Experiences Among Orthopaedic Surgery Residents in the United States Differs by Race and Gender

INTRODUCTION

Women and racial minorities remain underrepresented in orthopaedic surgery. While there is extensive research into the recruitment of these groups into the field, as well as more recent research regarding their representation in academic medicine and research, there is limited data on their experiences during residency. The purpose of this study is to assess the perceptions of orthopaedic surgery residents regarding their experiences during residency.

METHODS

In mid-2022, a voluntary survey was sent to 2,122 orthopaedic surgery residents addressing mentorship, access to opportunities, and "fit" within their residency programs. Responses were compared by race and gender, with 345 responses received, yielding a response rate of 16.3%.

RESULTS

Compared to male and Caucasian residents, female and underrepresented in medicine (URM) residents reported feeling less satisfied with the training they received, felt less supported, and perceived greater difficulty for women and minorities in being promoted within orthopaedics. Female residents also reported having less mentorship, receiving less recognition for their accomplishments, and being less satisfied with their career choice than male residents.

CONCLUSIONS

The results of this study highlight the need to improve equity and inclusion within orthopaedic surgery residencies in order to continue advancing diversity in the field.

Musculoskeletal Magazine Advertising Focuses on White Individuals and Overlooks Minority Consumers

INTRODUCTION

Demographic disparities in musculoskeletal (MSK) health exist in the US. Racial representation in advertising has been shown to influence consumer behavior and buying patterns. Direct-to-consumer advertising that does not target a racially diverse audience may exacerbate MSK disparities by failing to reach minorities. We explore the hypothesis that minorities are underrepresented in direct-to-consumer MSK advertisements in this cross-sectional analysis.

METHODS

Using magazines from four databases, eight health-related magazine types were selected and advertisement categories were established. Racial distribution was analyzed using Pearson's Chi-squared and Chi-squared tests. Fisher's Exact test was used when >20% of cells had expected frequencies <5. Significance was set at α = 0.05.

RESULTS

Of the advertisements featuring at least one model, 68.5% featured a white-presenting model, followed by 17.6% with a black model. Further, 92.7% of advertisements were monoethnic or monoracial with an overrepresentation of white models (p < 0.001). Black models were overrepresented as athletes (p < 0.001) and underrepresented in advertisements for pain relief (p < 0.001). Hispanic/Latinx and Asian models were underrepresented across all advertisement categories (p < 0.001).

DISCUSSION

The causes of musculoskeletal health disparities are multifactorial. One potential influence is adjacent industries such as MSK health-related advertisements. When controlling for US population demographics, white models were overrepresented and minority race models were underrepresented, demonstrating racioethnic disparities in MSK advertising. Improving the racial and ethnic diversity of models within MSK advertisements may serve to improve patient perceptions of orthopaedic products and services and improve MSK disparities.

The Sex or Race of Program Directors May Not Play a Significant Role in Impacting Diversity Among Orthopaedic Surgery Residents

PURPOSE

To identify the influence of residency program characteristics, including the presence of under-represented minorities in medicine (URiM) and/or female program directors (PDs), on the race and sex distribution of orthopaedic surgery residency trainees.

METHODS

All active and Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs from 2017-2021 that reported usable information in the Residency Explorer Tool were included. Data collected included program characteristics, as well as faculty and resident sex distribution, ethnicity, race, and demographic characteristics. The PDs' specific sex, ethnicity, race, and demographic characteristics were collected using residency program websites. The prevalence of factors in programs with the top quartile of female and URiM residents was compared with that in programs with the bottom 3 quartiles.

RESULTS

Data were obtained from 148 of 200 Accreditation Council for Graduate Medical Education-accredited programs (3,694 residents). The 52 excluded programs had no usable information in the Residency Explorer Tool or on an identifiable program website. Overall, 15.9% of residents in orthopaedic surgery residency programs were women and 14% were under-represented minorities. The rates of female PDs and chairs were 12.4% and 6.9%, respectively, whereas those of URiM PDs and chairs were 8.3% and 4.6%, respectively. Programs with more female residents were not associated with female PDs (P = .79) or URiM PDs (P = .48). Programs with a greater percentage of URiM residents were not associated with URiM PDs (P = .16). Larger programs (P = .021) and university-based programs (P = .048) had a greater percentage of female residents. Orthopaedic residency programs with visa sponsorship had a greater percentage of URiM residents (P = .017).

CONCLUSIONS

Programs with a higher percentage of female or URiM residents did not show a significant association with having female or URiM PDs. Larger programs and university-affiliated programs were more likely to have a larger percentage of female residents, whereas programs that offered visa sponsorship had a higher percentage of URiM residents.

CLINICAL RELEVANCE

This study highlights factors influencing diversity among orthopaedic surgery residents. Although the presence of female or URiM PDs does not influence the percentage of female or URiM residents, other program characteristics such as size, affiliation, and visa sponsorship offer potentially actionable insights for promoting greater diversity in orthopaedic training. Doing so may increase under-represented groups within the field and could ultimately impact patient care and improve health care equity.

Medical student non-modifiable risk factors and USMLE Step 1 exam score

For diversity to exist in the medical graduate workforce, students from all backgrounds should have equitable opportunities of employment. Specialties have utilized a minimal threshold for USMLE Step 1 score when screening applicants for residency interviews. The OHSU SOM class of 2021 completed a 14-question voluntary survey on their Step 1 score and the following non-modifiable risk factors: Adverse Childhood Experience score (ACEs), sex, gender, Underrepresented in Medicine status (URiM), family income during adolescence, highest degree held by a guardian, discrimination experience during medical school, federal/state assistance use, and rural versus urban primary home. Descriptive statistics and unadjusted risk ratios were applied to study the relation between Step 1 score and non-modifiable risk factors as well as certain non-modifiable risk factors and ACEs ≥ 3. The mean Step 1 score was 230 (213, 247). Of the students, 28.2% identified ACEs ≥ 3, 13.6% were considered URiM, and 65.4% were female. URiM were 2.34 (1.30, 4.23),females were 2.77 (1.06-7.29), and those who experienced discrimination in medical school were 4.25 (1.85, 9.77) times more likely to have ACEs ≥ 3. Students who had ACEs ≥ 3 were 3.58 (1.75, 7.29) times less likely to meet a minimal threshold for residency interviews of 220. These are the first results to demonstrate a relationship between Step 1 score and ACEs. Those who identified as URiM, females, and those who experienced discrimination in medical school were at a higher risk of ACEs of ≥ 3. Step 1 transitioned to pass/fail in January 2022. However, the first application cycle that residencies will see pass/fail scoring is 2023-2024, and fellowships will continue to see scored Step 1 until, at the earliest, the 2026-2027 application cycle. These data contribute to a foundation of research that could apply to Step 2CK testing scores, and help to inform decisions about the diversity and equity of the residency interview process.

A Comparison of Demographic Diversity Between Orthopaedic Surgery Residents and ACGME Foot and Ankle Fellows From 2007 to 2022

Background

Academic medicine emphasizes the need to recruit a diverse workforce in graduate medical education. Orthopaedic surgery residency has demonstrated efforts to model program compositions with evolving US demographics. However, it remains unclear whether orthopaedic fellowships, particularly foot and ankle, also reflect these efforts.

Methods

Using the publicly available Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book, a census of the gender and racial/ethnic identities of orthopaedic foot and ankle fellows, as well as active orthopaedic surgery residents, were compiled from 2007 to 2022. Linear trend analysis was conducted to evaluate the trends of orthopaedic residents and foot and ankle fellows, with a Pearson correlation for comparison.

Results

Prior analysis demonstrated no significant change in sex and ethnic diversity of fellows from 2006 to 2015. The majority of foot and ankle fellows were White (31%-69%) and male (63%-88%). Linear analysis demonstrated growing diversity in female and non-White active orthopaedic surgery residents. Similarly, there was an increasing number of female foot and ankle fellows (0%-38%) reflective of the trend in orthopaedic residency (12%-20%); however, there was no significant change among racial/ethnic identities. Pearson correlation analysis between the trend of orthopaedic residency residents and foot and ankle fellows suggests moderate correlation among female, Asian, and "Unknown" racial/ethnic categories.

Conclusion

The proportion of foot and ankle female fellows in ACGME-accredited fellowships has matched or exceeded the percentage of female orthopaedic residents. Despite increased diversity of orthopaedic surgery residents over the past 2 decades, ACGME-accredited foot and ankle fellowships do not yet reflect similar trends among racial/ethnic minorities.

Level of Evidence

Level III, retrospective cohort study.

The Effect of Underrepresented Minority Mentorship on Orthopaedic Spine Surgery Recruitment and Diversity: A 20-Year Analysis at a Single Institution

INTRODUCTION

Despite national efforts to increase diversity and inclusion, underrepresented minority (URM) representation among orthopaedic spine surgery faculty remains low. Research has shown that URM trainees are more likely to pursue surgical careers when they have access to URM mentors. The purpose of this study was to explore the influence of URM representation among spine faculty on the rate of URM orthopaedic residents pursuing spine surgery fellowships.

METHODS

From 2004 to 2023, data were collected from each residency class at our academic institution: residency year, number of residents per class (total and URM), and number of residents applying to spine surgery fellowships. These ethnicities were considered URM: Black or African American, Hispanic or Latino, and Native American. In 2018, two African American spine faculty were hired. Data were compared between Before and After their arrival. A subanalysis was done to include a period of increasing URM recruitment (2012 to 2018). Binary logistic regression analysis evaluated associations between appointment of URM faculty and fellowship choice of URM residents.

RESULTS

Two hundred fifty-six residents were included. Thirty-one total URM residents were in the program during the study period (12.1%). Overall, URM representation in the program increased over time [OR: 1.1, 95% CI: 1.1 to 1.2], whereas residents applying to spine surgery fellowships did not change [OR: 1.0, 95% CI: 1.0 to 1.1]. Comparing Before-2012 and 2012 to 2018 groups with the After-2018 group demonstrated a significant difference in the proportion of URM residents applying to spine surgery fellowships after the hiring of URM spine faculty (0.0% versus 23.1% versus 74.1%; P = 0.001).

CONCLUSION

This retrospective study provides empirical evidence of the importance of URM representation among orthopaedic spine surgery faculty and the potential effect on URMs pursuing orthopaedic fellowships. Institutions should consider prioritizing the representation of URM faculty in spine surgery to address the lack of current and future diversity in the field.

LEVEL OF EVIDENCE

III.