Evaluating the role of preference signaling on female representation in successful applicants in the orthopaedic surgery national resident match

The current U.S. orthopaedic residency application process is becoming increasingly impersonal in the wake of an increasing number of applications. Through an analysis of orthopaedic surgery residency application statistics, we have highlighted the effect that the number of orthopaedic applications has on match rate, and we have suggested methods for a more personalized application process. Data from the Association of American Medical Colleges (AAMC) and the National Resident Matching Program (NRMP) for United States orthopaedic residency applicants from 2008 to 2018 were collected. These data included the average number of applications submitted per applicant, the average number of applications received per program, the total number of residency positions offered in the U.S., the total number of U.S. applicants, and the total number of U.S. applicants who matched to a U.S. orthopaedic surgery residency program. U.S. applicant match rates and the average number of applications received per residency position offered were calculated. Linear regression models were used to determine the rate at which these variables changed over time. The average number of applications submitted by an applicant increased from 46.5 in 2008 to 74.9 in 2018. The average number of applications received per residency position offered increased from 54.1 in 2008 to 85.7 in 2018. The number of U.S. applicants was 740 in 2008 and 849 in 2018. The number of U.S. orthopaedic residency programs only slightly increased from 160 in 2008 to 171 in 2018. The match rate for U.S. medical school applicants has remained stable from 2008 to 2018 at a mean of 76.9% and a standard deviation of 2.3%. The match rate has remained stable from 2008 to 2018 despite an increase in the number of applications per position. This discrepancy suggests that increasing the number of submitted applications may not correlate with applicant success. We address this discrepancy and suggest methods that can potentially allow for a more targeted orthopaedic application experience.

Background Matching into competitive surgical specialties, including orthopedic surgery, has been a competitive task for medical students; however, Doctors of Osteopathic Medicine (DO) and females are some of the least represented groups in orthopedic surgery residency programs. While females represented nearly 50% of United States medical residents in 2023, they only represented 20.14% of orthopedic surgery residents. Female DO residents comprised less than 2% of orthopedic surgery residents in 2023. As interest in orthopedics rises for all medical students, it is crucial to look at the trends of how underrepresented groups are represented within the field of orthopedic surgery. Objective To determine how female DO graduates fare in the orthopedic surgery residency program selection process from 2020-2023 and to forecast data through 2033. Methods This is an analysis of publicly available data from the National Residency Match Program. Data from the National Residency Match Program was collected from 2020-2023 and included the total number of DO and MD orthopedic surgery applicants, the total number of female applicants, and the number of matched female DO and MD applicants. Additionally, the number of incoming female DO orthopedic surgery residents for the next ten years (2024-2033) was forecasted using a linear regression model, along with their corresponding confidence intervals. Results From 2020 to 2023, female orthopedic surgery residents increased in number (2020-2021: +58; 2021-2022: +61; 2022-2023: +86). Of DO orthopedic residents from 2020 to 2023, there was a steady rise in female DO residents. Female DO residents made up 10.17% of DO orthopedic residents in 2020, 11.09% in 2021, 10.80% in 2022, and 13.21% in 2023. Female DO residents saw a 50.94% increase while MD female residents saw a 28.66% increase from 2020 to 2023. Based on the most recent data from 2020-2023, we are expecting to see 160.71 ± 6.44 female osteopathic orthopedic surgery residents in 2033. The predicted annual percent change between 2023 and 2033 is between + 5% to 10%. Over the 10 years, that would be interpreted to be 8.29 more female DO residents annually. Conclusion Our study demonstrated that female osteopathic students comprise less than 2% of all orthopedic surgery residents. While the total composition of U.S. orthopedic surgery residents has shown an upward trend in female trainees, this value has only risen by 1.54% over four years. We hope that this research study increases awareness of the lack of DO female representation within the field of orthopedic surgery.

Background:Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown.Methods:Applicants to the home institution's orthopaedic surgery residency program were sent an optional online survey during the 2020 to 2021 application cycle. No incentive was provided in exchange for participation.Results:Of 812 orthopaedic surgery applicants, 650 (80%) completed the survey. Program-based social media is widely accessed by applicants. Instagram is used by most applicants (61.9%), and nearly a third (28.7%) rely on it as their main resource when researching prospective residency programs. The majority (66.9%) agreed that social media can be successfully used to inform and interact with applicants. Most of the applicants (60.6%) also reported that social media had a positive impact on their perception of the associated program. Only 5.7% of respondents indicated that social media had a negative influence. The most effective uses of social media seem to be in allowing a program to display its culture and transparency.Conclusion:Social media plays a substantial role in the orthopaedic surgery residency application process, and its use continues to grow. Programs can use it to effectively engage with and inform prospective applicants. The impact of social media is positive on most of the applicants. Instagram is the preferred social media platform used by applicants, and nearly one-third rely on it as their main resource when researching programs. Investing time and resources into a social media presence seems to be a worthwhile pursuit for orthopaedic surgery programs as an important piece to a well-rounded recruitment effort of modern orthopaedic surgery applicants.

Orthopaedic surgery is one of the most competitive but least diverse surgical specialties, with ever-increasing academic achievements (such as test scores) shown by applicants. Prior research shows that white applicants had higher United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge scores as well as higher odds of Alpha Omega Alpha status compared with Black, Hispanic, and other applicant groups. Yet, it still remains unknown whether differences in application metrics by race/ethnicity sufficiently explain the underrepresentation of certain racial or ethnic minority groups in orthopaedic residency programs. In this study, we sought to determine (1) the relative weight of academic variables for admission into orthopaedic residency, and (2) whether race and gender are independently associated with admission into an orthopedic residency. The Electronic Residency Application System (ERAS) data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) of first-time MD applicants (n = 8966) for orthopaedic surgery residency positions in the United States and of admitted orthopaedic residents (n = 6218) from 2005 to 2014 were reviewed. This dataset is the first and most comprehensive of its kind to date in orthopaedic surgery. Academic metrics, such as USMLE Step 1 and Step 2 Clinical Knowledge scores, number of publications, Alpha Omega Alpha status, volunteer experiences, work experience, as well as race and gender, were analyzed using hierarchical logistic regression models. The first model analyzed the association of academic metrics with admission into orthopaedic residency. In the second model, we added race and gender and controlled for metrics of academic performance. To determine how well the models simulated the actual admissions data, we computed the receiver operating characteristics (ROC) including the area under curve (AUC), which measures the model's ability to simulate which applicants were admitted or not admitted, with an AUC = 1.0 representing a perfect simulation. The odds ratio and confidence interval of each variable were computed. When only academic variables were analyzed in the first model, Alpha Omega Alpha status (odds ratio 2.12 [95% CI 1.80 to 2.50]; p < 0.001), the USMLE Step 1 score (OR 1.04 [95% CI 1.03 to 1.04]; p < 0.001), the USMLE Step 2 Clinical Knowledge score (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.001), publication count (OR 1.04 [95% CI 1.03 to 1.05]; p < 0.001), and volunteer experience (OR 1.03 [95% CI 1.01 to 1.04]; p < 0.001) were associated with admissions into orthopaedics while work and research experience were not. This model yielded a good prediction of the results with an AUC of 0.755. The second model, in which the variables of race and gender were added to the academic variables, also had a good prediction of the results with an AUC of 0.759. This model indicates that applicant race, but not gender, is associated with admissions into orthopaedic residency. Applicants from Asian (OR 0.78 [95% CI 0.67 to 0.92]), Black (OR 0.63 [95% CI 0.51 to 0.77], Hispanic (OR 0.48 [95% CI 0.36 to 0.65]), or other race groups (OR 0.65 [95% CI 0.55 to 0.77]) had lower odds of admission into residency compared with white applicants. Minority applicants, but not women, have lower odds of admission into orthopaedic surgery residency, even when accounting for academic performance metrics. Changes in the residency selection processes are needed to eliminate the lower admission probability of qualified minority applicants in orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery. Changes including increasing the diversity of the selection committee, bias training, blinding applications before review, removal of metrics with history of racial disparities from an interviewer's candidate profile before an interview, and use of holistic application review (where an applicants' experiences, attributes, and academic metrics are all considered) can improve the diversity landscape in training. In addition, cultivating an environment of inclusion will be necessary to address these long-standing trends in orthopaedic surgery. Race, but not gender, is associated with the odds of acceptance into orthopaedic surgery residency despite equivalent academic metrics. Changes in residency selection processes are suggested to eliminate the lower admission probability of qualified minority applicants into orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery.

Introduction:Although studies have evaluated the economic burden to medical students desiring an orthopaedic residency broadly, no study has evaluated in detail the application costs, away rotation costs, interview costs, and total costs. Given that the Association of American Medical Colleges and the American Orthopaedic Association's Council of Orthopaedic Residency Directors have recommended orthopaedic surgery residency programs for the 2021 residency application cycle cancel away rotations and in-person interviews, our objective was to evaluate the cost savings to medical students applying during this time and the potential implications.Methods:Using the 2019 to 2020 Texas STAR Dashboard database, we queried responses from applicants applying to orthopaedic surgery residency. The dashboard was queried to record the application costs, away rotation costs, interview costs, and total costs for medical school seniors applying to orthopaedic surgery residency. Demographic information for applicants was also recorded. Mean and median costs were reported with percentile distributions and geographic comparisons. A Kruskal-Wallis H test was used to determine whether there were statistically significant differences in mean costs by medical school region.Results:The 2019 to 2020 Texas STAR Dashboard database had 473 responses from applicants to orthopaedic surgery residency. The mean application costs were $1,990, away rotation costs were $3,182, interview costs were $3,129, and total costs were $8,205. The mean total costs for applicants from Midwest schools were significantly less than Western schools ($7,410/applicant vs. $9,909/applicant) (p = 0.008). There was no significant difference between the mean application fees between regions. Away rotation costs for applicants from schools in the Midwest ($2,413/applicant) were significantly less compared with Northeast ($3,279/applicant), South ($3,343/applicant), and West ($3,913/applicant) (all p < 0.002). Interview costs for applicants from schools in the Northeast ($2,891/applicant) were less than applicants from Western US schools ($3,831/applicant) (p = 0.038).Conclusion:In the COVID-19 era, orthopaedic residency applicants could save on average $6,311 through the use of virtual interviews and lack of away rotations. There are geographic implications, with applicants from Western US medical schools potentially saving most.

Our 2 previous studies (1999, 2007) examining misrepresentation of research publications among orthopaedic residency applicants revealed rates of misrepresentation of 18.0% and 20.6%, respectively. As the residency selection process has become more competitive, the number of applicants who list publications has increased. The purpose of this study was to determine current rates of research misrepresentation by orthopaedic surgery applicants. We reviewed the publication listings and research section of the Common Application Form from the Electronic Residency Application Service (ERAS) for all applicants applying to 1 orthopaedic residency program. The PubMed-MEDLINE database was principally used to search for citations. The PubMed Identifier (PMID) number was used; if no PMID number was listed, a combination of authors or the title of the work was used. If the citations were not found through PubMed, a previously developed algorithm was followed to determine misrepresentation. Misrepresentation was defined as (1) nonauthorship of a published article in which authorship was claimed, (2) claimed authorship of a nonexistent article, or (3) self-promotion to a higher authorship status within a published article. Five hundred and seventy-three applicants applied to our institution for residency in 2016 to 2017: 250 (43.6%) of 573 applicants did not list a publication, whereas 323 (56.4%) of 573 applicants listed ≥1 publication. We found 13 cases of misrepresentation among a total of 1,100 citations (1.18% in 2017 versus 18.0% in 1999 and 20.6% in 2007, p < 0.001). Ten cases of misrepresentation were self-promotion to a higher authorship status. There were 2 cases of claimed authorship of an article that could not be found. Only 1 applicant misrepresented more than once. Based on our findings, orthopaedic surgery residency applicants are accurately representing their publication information. The incorporation of the PMID number on the ERAS application has streamlined the process for finding publications, and has possibly encouraged veracity on residency applications. Faculty involved in the resident selection process should be aware of the significant decline in the rate of misrepresentation by medical students applying for orthopaedic surgery residency versus the rate in our prior studies.

Orthopaedic surgery residency applicants submit more applications than ever before. While this issue is multifactorial, increased information and transparency regarding residency programs are important. This study aimed to evaluate the completeness and variability of the information that is currently available regarding orthopaedic residency programs on two publicly available databases, the Fellowship and Residency Electronic Interactive Database (FREIDA) and the newly created Orthopaedic Residency Information Network (ORIN). Orthopaedic surgery residency programs were identified and evaluated using FREIDA and ORIN on September 11, 2021. Information on the FRIEDA and ORIN databases were evaluated in the following categories: program overview, the residency application, and education information. Univariate statistical analysis was performed on the data. Of the 194 programs that participated in the FREIDA database, over 48% failed to include basic program information including resident demographics and key application information including USMLE Step requirements. Of the 141 programs that participated in the ORIN database, most the programs did not report USMLE Step median and cutoff scores and clerkship grades. Depending on the database and type of information, factors including the program's National Institutes of Health funding, reputation, size, and type were associated with the availability of information. This study showed that while most orthopaedic surgery residency programs participate in FREIDA and ORIN, the information included was highly variable and incomplete for nearly all programs. Improving the completeness of information in these databases has the potential to allow students to make more informed application decisions.

Although women represented 58% of undergraduate students and 48% of medical students in the U.S. in the 2008-2009 academic year, only 13% of orthopaedic residents and only 4% of American Academy of Orthopaedic Surgeons (AAOS) Fellows in 2009 were women. Are all orthopaedic surgery programs in the U.S. equal in their ability to attract female medical students and train female orthopaedic surgeons? This study was undertaken to test the hypothesis that all Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery residency programs in the U.S. train a similar number of female residents. Data for all ACGME-accredited orthopaedic surgery residency training programs in the U.S. for five academic years (2004-2005 through 2008-2009) were collected with use of the Graduate Medical Education (GME) Track database. Orthopaedic residency programs in the U.S. do not train women at an equal frequency. In the academic years from 2004-2005 through 2008-2009, forty-five programs had no female residents during at least one of the five academic years reviewed, and nine programs had no female residents during any of the years. More than fifty orthopaedic residency programs in the U.S. had an average of &lt;10% female trainees over the five-year period, and more than ten programs had an average of &gt;20%. There was no significant change in the distribution among these categories over the five years examined (p = 0.234). Significant differences in the representation of women exist among orthopaedic residency training programs in the U.S. Further examination of the characteristics of orthopaedic residency programs that are successful in attracting female residents, particularly the composition of their faculty as role models, will be important in furthering our understanding of how orthopaedic surgery can continue to attract the best and the brightest individuals. Changes in the cultural experiences in programs that have not trained female orthopaedic surgeons, such as an increased number of female faculty, and policies that emphasize diversity may provide a greater opportunity for our orthopaedic profession to attract female medical students.

Introduction:This study assesses the accessibility and nature of parental leave policies during orthopaedic surgery residency training after implementation of the Accreditation Council for Graduate Medical Education (GME) mandate for 6 weeks of paid parental leave effective July of 2022.Materials and Methods:An audit of orthopaedic surgery residency and affiliated GME websites was conducted to assess the accessibility of parental leave policies during the 2023-2024 academic year. Details on length of leave and nature of renumeration during the leave were recorded. Bivariate analyses were conducted to determine residency program characteristics associated with the accessibility of a parental leave policy. Results were compared with a previous analysis during the 2017-2018 academic year.Results:A total of 200 residency programs were evaluated, and 152 had parental leave policies (76.0%). Compared with 2017 to 2018, a similar percentage of parental leave policies were accessible on residency program websites (3.0% vs. 2.0%, P = 0.777) but fewer were accessible on GME websites (55.5% vs. 80.7%, P < 0.001). More contemporary policies were obtained from program coordinators (18.5% vs. 7.2%, P = 0.003), and more were not available (24.0% vs. 9.0%, P < 0.001). Most policies offered renumeration (86.7%) and leave for 6 weeks in length (75.0%). A higher prevalence of parental leave policy accessibility was found among orthopaedic residency programs with university affiliation (P < 0.001), more faculty members (P = 0.008) and residents (P = 0.017), a higher percentage of female faculty (P = 0.008), affiliation with a top 50 ranked National Institutes of Health–funded orthopaedic surgery department, and accreditation achieved before 2017 to 2018 (P = 0.004).Discussion:Most orthopaedic surgery residency programs do not have accessible parental leave policies on their websites. The new Accreditation Council for GME mandate will require orthopaedic residency programs to provide residents with 6 weeks of paid parental leave during residency training. Accessible policies may be useful to applicants interested in child rearing during orthopaedic residency training.

Introduction In recent years, medical students and residents across the country have begun to utilize social media as a tool to connect. With more access to technology than ever before, medical students are using residency social media pages to find out more information about the culture of residency programs. Global pandemics, such as COVID-19, assisted in precipitating these changes in resident recruitment efforts due to truncated in-person interactions and limited sub-internship rotations. Additionally, the transition to virtual interviews further pushed medical students to find new ways to connect with residency programs. In response, orthopedic residency programs increased their social media presence to share information and facilitate virtual interactions with applicants. Our goal was to determine the platforms and content most influential for applicants choosing orthopedic surgery residency programs to assess the changing landscape of social media utilization. Methodology Applicants to a single academic orthopedic surgery residency program from 2017 to 2022 were surveyed. Participants were asked to describe personal use of social media, encounters with residency programs on social media, and perceptions of the social media presence and content of orthopedic surgery residency programs.Surveys were distributed to participants via email including a description of the study requesting voluntary participation. Each subject received, at most, one reminder email. The data was analyzed to determine applicant perceptions of the social media presence of Orthopedic Surgery residency programs. Results The survey was distributed to 3690 applicants to Penn State's Orthopedic Surgery Residency Program from the entering class of 2018-2022 in addition to the 19 Penn State fourth-year medical students applying to Orthopedics. A total of 102 people responded to the survey, with a response rate of 3.1%. Of the total number of respondents,88.2% thought Instagram was the best platform for a residency program to use, and over 65% of respondents would use Instagram to interact with a residency program. Most respondents prefer Resident Biographies, Social Gatherings/Family Life, Day-in-the-Life, Program Culture, and Attending Biographies posted on the Instagram page every week. Applicants observed drinking, politics, and sexist language on social media pages of orthopedic surgery residency programs that were undesirable and caused a negative perception of that program. Conclusions Social media usage has drastically increased in recent years. Global pandemics and increased social media usage among the US population have allowed social media platforms to become a powerful tool for marketing orthopedic surgery residency programs. This survey study examined applicant perceptions of the social media presence of orthopedic surgery residency programs. Instagram was the most widely used and influential. According to surveyed participants, programs desiring to create the most positive impact through social media should aim for weekly posts highlighting the people, events, and everyday life of the orthopedic residency while avoiding controversial content that may ostracize applicants.

CORR® curriculum--osteopathic and allopathic residency education: Why not the same standards?

Have Degree, Will Travel? Geography and Orthopaedic Surgery Residency Match

Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed? All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected. Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave. Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training. Parental leave policies are increasingly relevant to today's trainees []. Applicants to orthopaedic surgery today value work/life balance including protected parental leave [].

Lack of racial diversity remains a persistent problem in medicine, most notably in the field of orthopaedic surgery. In 1999, an analysis by England and Pierce of orthopaedic residents who had been selected for residency programs from 1983 to 1995 found that the percentage of Blacks, Hispanics, and Native Americans had changed minimally over that 12-year period1. During that time, the rate of Black orthopaedic residents in training never surpassed 3.5%. In the >2 decades that have followed, there has been a continued call to increase recruitment of underrepresented minorities (URMs), particularly Blacks, into orthopaedic surgery2-6. Despite these directed efforts, orthopaedic surgery remains the least racially and ethnically diverse field among both surgical and nonsurgical specialties7,8. Lack of racial diversity correlates with substantial disparities in the culturally competent care of minority patients, with well-documented negative implications9-11. Improving diversity within our specialty is essential to achieving equitable postoperative and functional outcomes in our diverse patient population. While barriers to improving gender diversity have been and should continue to be explored, the profession of orthopaedic surgery must critically evaluate the barriers to recruiting URM applicants, particularly Black applicants. This is essential to help usher in the next decade with a racially diverse, inclusive, and equitable workforce. This article serves as the first in a series exploring the barriers to achieving a diverse, inclusive, and equitable environment for Black orthopaedic surgeons. The focus of the article is to examine the barriers to successful recruitment of Black applicants and provide tangible recommendations for improving racial diversity in residency. What Obstacles Do Black Candidates Face in Matching into Orthopaedic Surgery? The barriers to Black students' pursuit of orthopaedic surgery as a career are both intrinsic and extrinsic. Intrinsically, Black students assess the career choices that are available to them by evaluating what those in their own communities are doing or are expected to do. In a 2013 article, Hill and Vaughan explored the concept of "paradigmatic trajectories" to explain ways that students self-select out of pursuing surgical specialties12. Black medical students are frequently unable to see, identify, or interact with orthopaedic surgeons who look like them. These students are repeatedly informed about the difficulty of getting into orthopaedics and are denied "experiences of participation," which leads them to being unable to see themselves as orthopaedic surgeons. By contrast, their majority peers often have the opposite experience: they see many available role models in orthopaedics who match their demographic, serve as role models, and provide hands-on experiences. As this scenario is repeated each academic year, the disparity between the number of White and Black medical students choosing to pursue orthopaedics as a specialty increases, a process that, to date, appears perpetual. Extrinsically, the pipeline of minority students to orthopaedic residency positions is filled with detours due to the redirection of minority students to other career pathways. This discouragement begins early for Black students, particularly Black male students, especially in educational environments in which their teachers are White. A study using survey data from the Education Longitudinal Study of 2002, which was conducted by the U.S. Department of Education's National Center for Education Statistics, evaluated how teacher expectations influenced student performance among 6,000 high school students13. It found that there were clear racial disparities in teacher expectations of student performance. For example, the study found that teachers expected 58% of White high school students to obtain a 4-year college degree, but expected only 37% of Black students to do so. Furthermore, when considering these same Black students, White teachers were significantly less likely than their Black colleagues to expect the students to achieve a 4-year college degree. This difference was even more pronounced when the student was a Black male. Ultimately, the study concluded that negative expectation bias contributed to a self-fulfilling prophecy: only 29% of Black students in the study obtained a 4-year degree. Certainly, diminished expectations of Black students may carry similar consequences in higher education. For Black medical students, the lack of early exposure to orthopaedic surgery and the elimination of student-generated stereotypes regarding their potential fit for the specialty are critical roadblocks to increasing applications to residency programs. Schmidt et al. noted that the timing of exposure and student-perceived stereotypes, among other factors, were major determinants in a medical student's decision to pursue surgery14. An early introduction to the field of surgery was particularly important in increasing a student's interest in a surgical career. For those Black students who persevere in choosing orthopaedics, being chosen for an orthopaedic residency program is still problematic. The benchmarks that are used for resident selection are arbitrary at best, and biased and discriminatory at worst. In the 2018 National Resident Matching Program (NRMP) survey of program directors15, 91% of orthopaedic residency program directors cited the United States Medical Licensing Examination (USMLE) Step-1 score as the most important factor for selecting students to interview. Membership in the Alpha Omega Alpha (AΩA) honor society was the third most important factor listed, and the Medical Student Performance Evaluation (MSPE) was noted as the seventh factor. Ramkumar et al. confirmed that orthopaedic surgery interview offers for applicants correlated most with AΩA status, the Step-2 Clinical Knowledge score, and the Step-1 score16. This has important implications for URM students. Wijesekera et al. reported that the USMLE perpetuates downstream pipeline disparities stemming from parental education or socioeconomic status, especially for URM students17. Clinical clerkship evaluations and the MSPE have demonstrated a negative bias toward Black students compared with their White counterparts18, and there are implicit differences in the words that are used to describe different ethnic groups19. Boatright et al. reported that Black students were less likely than an equivalent White student to be selected for the AΩA honor society, even after controlling for Step-1 scores, research, leadership roles, and membership in the Gold Humanism Honor Society20. The data reveal that there is inherent bias in the objective measures that are used by orthopaedic surgery programs to vet their applicants. Although the current measures select excellent future orthopaedic surgeons, these measures ultimately favor a specific group, which is defined by Rubright et al. as "a native English-speaking White male U.S. citizen at average age"21 at the expense of applicants who do not fit this mold. What Current Strategies Have Been Implemented to Increase the Number of Black Medical Students Applying into Orthopaedic Surgery? In 2020, racial inequality, health disparities, and social injustice have played a central role in the civil discourse within and outside of the field of medicine. The lack of racial and ethnic diversity in orthopaedic surgery deprives the specialty of the diversity of ideas and lived experiences that can speak to social issues that affect our diverse patient population. Different national organizations have attempted to champion diversity efforts in orthopaedics. The American Academy of Orthopaedic Surgeons (AAOS) has incorporated diversity initiatives into its strategic goals. These goals include understanding and responding to the diversity of the patient population, enhancing the delivery of culturally competent care, and supporting efforts to diversify the profession and the orthopaedic workforce. Despite these efforts, orthopaedic surgery still critically lags behind other subspecialties with regard to increasing the diversity of its surgeon workforce, which speaks to a critical need to further prioritize diversity in orthopaedics through a coordinated multidisciplinary approach. At the 2011 AAOS/ORS (Orthopaedic Research Society)/ABJS (Association of Bone and Joint Surgeons) Musculoskeletal Healthcare Disparities Research Symposium, Dy and Nelson proposed that cross-cultural communication and workplace diversity should be valued by all orthopaedic surgeons and should be championed by the leaders of academic orthopaedic departments2. They suggested that structured collaborative initiatives should be implemented by departmental leadership at each medical school in coordination with female and URM orthopaedic surgeon role models. Furthermore, they recommended that national orthopaedic societies like the AAOS should work in concert with diversity-minded orthopaedic associations such as the Ruth Jackson Orthopaedic Society, the J. Robert Gladden Orthopaedic Society (JRGOS), and the American Association of Latino Orthopaedic Surgeons to recruit and prioritize the mentorship of underrepresented populations into the field of orthopaedic surgery. In tandem with the efforts of the AAOS, mentoring pipeline programs such as Nth Dimensions coach applicants on how to prepare and position themselves as highly qualified applicants into the field of orthopaedic surgery. Nth Dimensions has developed a longitudinal pipeline curriculum that is designed to engage medical students in their first year of medical school. The program has multiple phases that maintain contact after exposure, including webinars, symposia, and an immersive summer internship program, as well as longitudinal mentorship and professional development. The program intentionally exposes students to multiple hands-on experiences through bioskills workshops and physician-shadowing. In addition, Black students are exposed to an extensive network of Black orthopaedic surgeons with a wide variety of lived experiences. From the initial contact through residency completion, the Nth Dimensions "community" reinforces orthopaedics as a viable career. This exposure was found to significantly increase the odds of URM participants applying to orthopaedic residencies by 15-fold22,23. To our knowledge, no other pipeline programs that focus on improving racial diversity within medicine exist with data to support their success. For Programs That Historically Lack Ethnic Diversity, How Can Residency Program Leadership Increase Recruitment of Black Orthopaedic Residents? A study by Adelani et al. recently reported that the number of orthopaedic training programs with no Black residents actually increased from 40 programs in 2002 to 60 programs in 2016, with the worst year being 2011, when 76 programs had no Black residents24. Recently, McDonald et al. surveyed program directors and coordinators on perceived barriers to increasing the diversity of their individual orthopaedic programs25. Nearly 70% of respondents said that the lack of enough URM faculty hindered their ability to recruit URM applicants. Fifty-six percent of programs responded that they consistently ranked URM applicants to match, but these applicants matched elsewhere. Fifty-five percent of programs felt that their programs could be more diverse, but the programs simply did not receive enough applications from URMs. Interestingly, 32% of programs were not specifically trying to recruit URM applicants at all. While pipeline programs such as Nth Dimensions provide a solid foundation for improving the number of Black students pursuing orthopaedics, future strategies need to implement program-level initiatives to further these goals. Orthopaedic residency programs that are affiliated with medical schools should nurture an early interest in orthopaedic surgery and musculoskeletal care among Black and other URM applicants through endorsement of a musculoskeletal education curriculum for medical students. Early exposure to orthopaedic surgery fosters more interest in the field, particularly among minorities and women22,23. Bernstein et al. reported that medical schools that required instruction in musculoskeletal medicine had significantly higher rates of application to orthopaedic residency programs26. This difference was even more pronounced among female and URM medical students. On a broader scale, increasing the diversity of orthopaedic faculty has downstream implications in the growth of diversity in residency programs. Okike et al. reported that URM medical students who attended medical school at institutions with high URM representation among orthopaedic faculty (>8.8%) or orthopaedic residents (>10.5%) were more likely to apply into orthopaedics than those with low URM representation among orthopaedic faculty (<4.0%) and orthopaedic residents (<6.1%)27. We would also submit that simply hiring Black faculty is not sufficient to move the needle toward a more diverse workforce. To improve racial equity and inclusion, there needs to be a concerted effort to support and advocate for Black faculty in leadership roles within orthopaedic departments and on a national level. We also suggest that orthopaedic department leadership become actively involved in diversity-related orthopaedic organizations such as the JRGOS and Nth Dimensions. This offers opportunities to interact with the majority of Black residents, fellows, and faculty within the orthopaedic specialty nationwide, and goes a long way toward improving a culture of inclusion within the field. Nearly every medical school in the U.S. has local chapters of medical student URM groups such as the Student National Medical Association (SNMA) and the Latino Medical Student Association (LMSA). Sponsorship of an SNMA or LMSA meeting by the affiliated orthopaedic department provides a rich opportunity to interact with Black and other URM students and provides exposure to the orthopaedic specialty. This also allows faculty to interact with more Black students, developing critical mentorship and sponsorship opportunities for these students that not only foster a more inclusive environment within that orthopaedic program but develop critical pipelines for future Black faculty recruitment and development. In "Ten Key Steps for Chairs, Program Directors, and Faculty to Serve as Allies During This Racial Crisis," Ross et al. highlighted the importance of developing transparent nationwide metrics on racial diversity in orthopaedics28. This concept mirrors that of the value-based care philosophy that links financial incentives to surgeon performance on a set of defined measures29. The JRGOS has the most comprehensive database of Black orthopaedic surgeons in the U.S. Based on their data, a diversity ranking was created for the 2020-2021 academic year30. Of the 56 orthopaedic residency programs that had Black residents this academic year, the following programs were ranked in the top 5 in terms of the highest percentage of Black residents: Howard University (70%), Tulane University (27%), Kingsbrook Jewish Medical Center (20%), New York University (15%), and Stanford University (14%). One argument against ranking metrics such as these is that they could potentially foster competition between programs for a small finite population of qualified Black applicants. However, the counterargument to this would be that the applicant pool is not truly finite. Poon et al. evaluated orthopaedic applicants between 2005 and 2014 and found that 5.7% were Black applicants and 71% were White applicants8. However, during that same period, only 3.8% of orthopaedic matriculants were Black while 74.7% of orthopaedic matriculants were White (an acceptance rate of 46% versus 73%). As established diversity pipeline initiatives increase the number of Black and other URM applicants into orthopaedic surgery, there needs to be an increase in the acceptance and retention of these students among a broader group of residencies. Recruitment of Black and other URM applicants must be an active and sustained effort. Diversity metrics such as the JRGOS rankings allow residencies that lack diversity to objectively compare themselves with more diverse programs on a granular level. However, we would further argue that program-level information on underrepresented populations in orthopaedics should be readily available through national orthopaedic associations such as the AAOS or the American Orthopaedic Association (AOA). Furthermore, programs should perform an objective and critical analysis of negative factors that have impeded the recruitment and retention of Black residents and faculty at their programs. These factors could contribute to the outward perception of a noninclusive, even hostile, environment, which could deter Black applicants from considering a program. Exploring the root causes that impede diversity may not achieve immediate gains in recruitment, but may help prepare a program for future Black applicants. These applicants will eventually recognize concerted efforts by a program for achieving inclusive culture, and they may choose to attend a program that may not historically have been diverse. The successful recruitment of Black applicants into the field of orthopaedic surgery also requires that the resident selection process eliminate unconscious biases in the screening of potential applicants. One means of achieving a diverse selection pool is to modify the screening criteria of potential applicants. Blind screening of potential candidates has been proposed as a way to mitigate racial, ethnic, gender, and medical school bias in the screening process28,31. Fadem et al. found a significant correlation between the income level of a medical student's parents and that student's Medical College Admission Test (MCAT) and USMLE scores for both minorities and nonminorities32. A study evaluating general surgery applicants found that discrete USMLE cutoffs eliminated URM applicants at a higher rate than non-URM applicants33. The concept of "distance traveled" is another screening process that is used in the technology and corporate sectors as a means of mitigating unconscious bias in hiring practices, which have favored more privileged and homogeneous applicants34,35. The "distance-traveled" concept factors in where a job candidate came from and how many obstacles he or she had to overcome to get to where he or she is currently. Recently, medical schools have used "distance-traveled" metrics to admit a more racially/ethnically, culturally, and financially diverse group of medical students while deemphasizing reliance on standardized test scores in screening practices36,37. As the USMLE Step-1 shifts to a pass/fail format from the numerical score format that has been perceived as disadvantageous to minority students38, use of a "distance-traveled" screening measure may allow for the prioritization of candidates from diverse backgrounds who demonstrate higher levels of resilience and "grit," which are considered desirable traits among successful orthopaedic residents39,40. Furthermore, we recommend that all selection committee members at residency programs should complete bias/allyship training prior to the selection process. In a study by Capers et al., investigators evaluated the value of identifying bias in medical school admissions41. All 140 members of the Ohio State University College of Medicine (OSUCOM) admissions committee were administered the Black-White Implicit Association Test (IAT) prior to the 2012-2013 application cycle. All of the groups surveyed, particularly male members and medical school faculty, demonstrated a significant White male preference. The IAT results were released to the participants, with 48% admitting that they were conscious of their individual results when interviewing candidates during the next application cycle. This information resulted in measurable change: the class that matriculated following the IAT exercise was the most diverse in OSUCOM's history at that time. The implementation of comparable bias training programs within orthopaedic residencies may achieve a similar effect. Summary Orthopaedic surgery has the lowest percentage of Black representation of any specialty, and there has been minimal to no improvement on this front over the last 2 decades. As racial and ethnic inequities in America are increasingly highlighted, it is clear that orthopaedic surgery as a field has fallen short regarding diversity. Orthopaedic surgery can improve its racial diversity with concerted effort and the active engagement of future applicants of color. We recommend active recruitment of Black applicants with the utilization of established pipeline programs and organizational resources. Furthermore, strategies to increase the number of Black applicants to orthopaedic residency programs require paradigm shifts in medical students' perception of orthopaedics as a viable career path and strategic preparation of residency program environments for URM-resident recruitment. Most importantly, programs must take a proactive role in creating a safe and fair working environment for their URM residents. Our hope is that these strategic collaborations can contribute to measurable change in racial diversity in orthopaedics over the next decade.

The role of research in the orthopaedic surgery residency application process has become increasingly important, particularly in the wake of the United States Medical Licensing Examination (USMLE) Step 1 examination transitioning to pass/fail. The purpose of this study was to determine the value that orthopaedic surgery residency program directors and other faculty place on various research elements included in residency applications. An anonymous cross-sectional survey was distributed to program directors and other faculty involved with the review of orthopaedic surgery residency applications within the Collaborative of Orthopaedic Education Research Group in February 2024. The survey asked questions related to the value placed on publication types, authorship position, dedicated research years, and the general importance of research. Ten respondents, including 7 program directors, 2 assistant program directors, and 1 director of research, participated. Eight (80%) indicated that the number of publications is important, with 4 (40%) identifying a minimum number of publications of 2 to 3 to be considered competitive at their program. Respondents also identified the following components as important: journal impact factor (9; 90%), authorship position (5; 50%), and study type (7; 70%). Clinical research within orthopaedic surgery was most highly regarded (9; 90%), while case studies were deemed least valuable (9; 90%). Six respondents (60%) agreed that research is more important now that USMLE Step 1 is pass/fail. Since the transition of Step 1 to pass/fail, research has become an increasingly important part of an orthopaedic surgery resident's application. Residency programs value research productivity, particularly clinical research within orthopaedics. While the minimum number of publications varies, 2 to 3 are often considered competitive. Factors contributing to the perceived value of research include journal impact factor, authorship position, and study type. With this knowledge, applicants can align their research activities with the values of orthopaedic surgery residency programs. Level IV. See Instructions for Authors for a complete description of levels of evidence.