1. Julieanne P. Sees, DO, MBA, FAOAO, FAOA, FAAOS Pediatric Orthopaedic Surgeon, Fellow of Osteopathic Medicine – National Academy of Medicine
2. Ahmed Nahian, BS Osteopathic Medical Student – Lake Erie College of Osteopathic Medicine
3. Ryan Johnson, BA Clinical Research Specialist – Capitol Technology University

Abstract

OBJECTIVES
Osteopathic match rates in competitive specialties, such as orthopaedics, have been under intense scrutiny. This study aimed to quantify trends in the characteristics of Osteopathic Orthopaedic Surgical Residency training and education from graduating classes of 2010-2020.

METHODS
This was a retrospective evaluation of a large, longitudinally maintained database of the American Osteopathic Association (AOA) from orthopaedic residency graduating classes of 2010-2020. Trends in characteristics were analyzed, including the resident’s age at graduation from medical school and residency, gender, advanced degree status, College or School of Osteopathic Medicine (COM/SOM), residency, and residency class year.

RESULTS
Overall, the number of osteopathic orthopaedic residents had a 32.9% increase from 85 to 113 per year, graduating over the past decade. Statistical forecasting predicts a 27.8% increase in osteopathic orthopaedic residents over the next decade. The percent composition of osteopathic students entering orthopaedic residency class by gender remained relatively stable. The average percent male composition of the orthopaedic residency class was 90.5%, ranging from a maximum of 96.1% and a minimum of 83.7%. While the average percent female composition of orthopaedic residency class was 9.5% for the past decade, statistical forecasting predicts that over the next decade, the average percent composition of females in orthopaedic residency will be 5.8%. The average age of residents at graduation was 33.4 years, while across the decade, resident age at graduation decreased by 9.8%. On average, female orthopaedic residents at graduation were younger than male orthopaedic residents. Osteopathic Postdoctoral Training Institute (OPTI)-West/Community Memorial Health System Orthopaedic Surgery Residency had the highest average age at residency graduation (35.7 years), and Lake Erie COM/York Hospital Orthopaedic Surgery Residency had the youngest average age at residency graduation (32 years). Edward Via COM-Carolinas Campus had the highest average age at graduation from medical school (30.5 years), and Touro COM had the lowest average age at graduation from medical school (26.7 years). Only 3.3% of osteopathic orthopaedic residents had additional advanced degrees. Philadelphia COM produced the most significant number of orthopaedic residents (89) and trained the most female orthopaedic surgeons of any program over the ten years.

CONCLUSIONS
The number of osteopathic medical students entering orthopaedics has increased over the past decade. However, there remains a lack of a similar increasing trend of female osteopathic medical students entering osteopathic orthopaedic residency programs. Interestingly, the age of osteopathic orthopaedic residents at graduation decreased across the decade, while advanced degrees did not play a statistically significant factor in matching into orthopaedic surgery. The osteopathic medical school was the most significant predicting factor in matching into orthopaedic surgery. With such knowledge, greater efforts should aim to enhance osteopathic medical student exposure to orthopaedic programs to maintain quality candidate interest in this competitive field, including female prospects, while also increasing the holistic diversity of characteristics within the field of orthopaedic surgery.

KEYWORDS
Orthopaedics, Orthopaedic Surgery, Osteopathic, Graduate Medical Education, Residency, Medical Students

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Introduction
Orthopaedic resident selection is quintessential to the growth and development of an orthopaedic surgery department and healthcare as a whole, especially when considering the resident workforce’s contribution to achieving goals for quality and safety. However, no prior studies have examined osteopathic orthopaedic surgery resident characteristics. The previous decade marked a pivotal American Osteopathic Association (AOA) merger with the American Council of Graduate Medical Education (ACGME) while precipitating fundamental changes to the course of graduate medical education (GME) in the United States of America (USA). In 2020, the American Osteopathic Graduate Medical Education (AOGME) system of the AOA transitioned to a single GME accreditation system as a result of this five-year transition that began in July 2015 and concluded in June 2020. With ACGME serving as the accreditor of all physicians and surgeons in the USA, previous orthopaedic programs solely accredited by the AOA completed this transitional process. Therefore, it seems advantageous to investigate former AOA-approved orthopaedic surgery programs within the context of distinctive osteopathic orthopaedic resident characteristics to serve residency applicants and faculty responsible for shaping the future of these transitioning programs under a unified graduate medical education system and for the holistic success of the osteopathic orthopaedic surgical workforce. 

Historically, orthopaedic residency programs have been among the most competitive specialties sought by medical students. Consequently, orthopaedic residency programs uphold their legacy of quality resident selection accomplished through candidate review by the designated residency program’s selection process. Acknowledging this reality, examining the osteopathic resident characteristics is vital to gaining objective insights into residency program selection criteria and trends. For example, one article attempting to define applicant fit and diversity in the orthopaedic surgery residency selection process considered various criteria in the selection process as perceived fit.1 Diversity is a phrase that can refer to a wide range of candidate demographics; it is typically used to describe racial and sexual differences, while age, financial status, and life experiences might offer a helpful lens for medical and surgical care delivery within this context. Another review within ACGME data collection published in 2021 highlights that 37 ACGME programs out of 150 total programs had no female residents; 53 programs had >20% female representation, and while female medical students continued to pursue orthopaedics at varying rates (9.8-15.4% compared to males), there remains a lag in demographic diversity when comparing orthopaedic surgery residency programs against those of other surgical specialties.2 Having no reports recorded in the literature of purely osteopathic orthopaedics, our current study aims to investigate USA orthopaedic surgery training programs solely under the previous AOA accreditation for students entering residency for ten consecutive years within the last decade. Our purpose is to explore qualitative and quantitative changes within the osteopathic orthopaedic surgical workforce and its distinctive characteristic trends prior to the ACGME accreditation transition. 

Methods 
To understand the trends of medical student characteristics in osteopathic education who matched into an osteopathic orthopaedic residency, data for all orthopaedic surgery residency programs provided by the AOA’s database were analyzed for ten consecutive academic years from 2010 through 2020. The qualitative data collected included: residency program, residency program state, residency program class (to include start and end date), transfer information (if applicable), resident gender, college/school of medicine (COM/SOM), medical school graduation class, age at graduation from medical school and residency, additional graduate degrees at the time of application to residency, and board certification. This study was declared exempt by the Institutional Review Board, given that all data utilized were publicly available. Statistical analysis was performed with Microsoft Excel to include mean values, median values, standard deviation, interquartile ranges, Chi-squared, and Fisher’s exact tests were used for analysis, when appropriate, to evaluate categorical variables. 

Results 
In 45 formerly AOA-accredited orthopaedic surgery residency programs, osteopathic orthopaedic surgery interns had a mean age of 28 ± 2.6 years at the start of their orthopaedic surgery residency. Resident age decreased across the decade from a mean of 33.4 years old at the time of graduation from residency to 33.0 years old, Figure 1. The mean gender composition of the osteopathic orthopaedic surgery resident classes spanning the previous decade was 91% (n= 947) male and 9% female (n= 99), Figure 1. The orthopaedic male resident class composition ranged from 84-96%. Meanwhile, the orthopaedic female resident class composition ranged from 4-16%. The COM/SOM attended was a significant factor in determining a residency applicant’s successful match into orthopaedic surgery residency, supplemental Figure 3. 29 out of a total of 38 osteopathic medical schools successfully produced at least one graduate who successfully matched into orthopaedic surgery residency across the last decade. Philadelphia College of Osteopathic Medicine (PCOM) produced the greatest number of orthopaedic surgery residents of any single campus (n=89). Interestingly, LECOM has the most number of orthopaedic surgery residents produced, including all affiliate campuses (n= 108). On the contrary, Edward Via College of Osteopathic Medicine – Carolinas Campus produced the fewest (n=2) orthopaedic surgery residents among those schools that produced at least one orthopaedic surgery resident. Additional advanced degrees did not provide candidates with an advantage in matching into orthopaedic surgery residency. The most prevalent additional graduate degrees at the residency application time was a tie between MS and MBA (n=8). The second most prevalent graduate degree was MPH (n=6). DO/Ph.D. dual degree accounted for .02% (n=3) of osteopathic orthopaedic surgery residents. Additional degrees represented were DPT/MPT, PharmD, MSc, MHS, ATC, and MS Medical Education.

Residency programs were evaluated by resident age selection and advanced degree status, among other factors. As a result, PCOM Orthopaedic Surgery Residency Program graduated the most significant number of orthopaedic surgery residents (n=66). A limitation of the data available for PCOM is that the specific PCOM sites were not specified in the source data. Meanwhile, Henry Ford Orthopaedic Surgery Residency graduated the fewest.

Many COMs demonstrated a statistically significant relationship, as feeder schools, to residency programs. Des Moines COM students were most likely to match at KCU-GMEC residency sites (p = 2.04*10^-5). Similarly, KCU-COM students were most likely to match at KCU-GMEC residency sites (p = 1.34*10^-7). LECOM students  were most likely to match at LECOM residency sites (p = 0.03). AZCOM students were most likely to match into OPTI-West/Good Samaritan Regional Medical Center OSR Program (p = 1.61*10^-7). OU-HCOM students were most likely to match into CORE/Grandview Hospital and Medical Center OSR program (p = 1.7*10^-5). NOVA-COM students were most likely to match into CEME/N Broward District Hospital OSR (p = 9.76*10^-5). PCOM students were most likely to match into PCOM OSR sites (p = 6.3*10^-5). MSU-COM students were most likely to match into SCS/MSUCOM sites (p = 9.06*10^-21). MWU-COM students were most likely to match into MWU/OPTI/Franciscan Health Olympia Fields OSR (p = 5*10^-3).

Discussion
This report considered trends and changes during the past ten consecutive years (2010-2020) in the distribution of characteristics of osteopathic orthopaedic surgical residency programs. A significant positive trend was demonstrated with an overall increase in the number of osteopathic orthopaedics trainees over the past decade, with generally minimal changes in the percent composition of a class of characteristics available for review. Since its establishment 130 years ago, the osteopathic profession has evolved, including over the last decade, with an increase in the number of students attending osteopathic medical school growing 77% and an overall increase in the proportion of female DOs in active practice over the past decade by 18%. It remains one of the fastest-growing segments of healthcare within the USA.³ With these optimistic factual trends, the combination of orthopaedic surgical expertise, and the advantage of training emphasis on the musculoskeletal system in osteopathic medical education, the future contribution of osteopathic orthopaedists to our workforce remains distinctively critical.

Age at graduation may play an essential role in the decision to pursue surgical residencies, which tend to be longer than non-surgical routes. In the case of orthopedic surgical residency, the minimum duration of training is five years. Regarding age in our cohort as a notable characteristic, the average age at the start of residency tended to decrease over the decade by approximately three years. Unfortunately, there have been no reports on such factors specifically for aspiring orthopaedic medical students. It has been reported in the literature, however, that up until the age of 24, both psychosocial and judgmental maturity exhibit a consistent progression (Steinberg and Cauffman 1996), while females seemed to have substantially higher emotional intelligence (EI) than males in a survey of medical school applicants in the USA with components of EI were maturation, sensitivity, morality, sociability, and calm temperament (Carrothers et al. 2000). In comparison to the 2010 American Association of Colleges of Osteopathic Medicine Matriculant Summary, the average age at matriculation for osteopathic medical students was 25 years.⁴ Similarly, the mean age of medical students at anticipated matriculation from 2014-2018 for both men and women, according to the American Association of Medical Colleges, was 24.5. In concert with the context of these reports, the average age medical student to complete longitudinally in orthopaedic surgery pursuit within a continuous five-year GME track projects residency graduation at 29 years of age. Our review is heading toward this trend for osteopathic orthopaedic residents. 

The overall composition of females within osteopathic orthopaedic residency classes remains minimally changed as an overall trend, while there are notable variations in comparing particular years throughout the decade. Similarly, this is reported in ACGME-accredited allopathic orthopaedic programs in a 15-year report where the percentage of women during each academic year varied, and the average trend in orthopaedics remained slightly lower overall. The authors demonstrated that about one-third of programs still train 0 to 1 women and projected their goal of 30% women within orthopaedic surgery residency training programs would not be achieved until 2060.² While it is not clear to the authors the allopathic training position opportunities per residency class, it is of worthy note that in traditionally osteopathic orthopaedic residencies the actual differences in the number of residents per year greatly may vary not only across programs but within programs having uneven distribution between levels of residencies attributing to some variation internally. Additionally, regarding the presence of female residents, this factor was ranked in the top 5 most important for female applicants pursuing a discipline within graduate medical education.⁶  According to geography, the lowest female representation in orthopaedic residencies is seen in the South, the highest in the Northeast and West, and the Mid-Atlantic region represents the lowest percentage of female orthopaedic faculty of 5.6% compared to 18% in mountain regions.^7-8 Diversity in gender has been shown to enhance education and patient care, where patients seem to prefer treatment by physicians of the same sex along the age spectrum.^9-10 While our study could not capture these specific factors, there is a relative effect and interest in addressing such trends across medical graduate education, faculty, and ultimate practice in future considerations within the healthcare workforce.

While foundationally, medical education plays a crucial role in shaping students, as demonstrated in our analysis, the influence composition continues to be complex. Pipeline programs and early exposure have been proposed to impact the pursuit of an orthopaedic career positively.^11-12 Coupled with this concept, it has been recorded that medical students pursue the fields of their choice based on additional considerations specifically regarding specialty, including orthopaedic based on lifestyle/quality of life issues and on the subject matter itself.¹³ Lack of exposure early in training and medical school experiences have been shown to affect students’ interest in orthopaedics which may be a factor in the stagnant trend of female pursuit in osteopathic programs.^14-15 And, in reference to predominantly allopathic medical education, the highest factor considered medical school exposure with mandatory musculoskeletal instruction during medical school was associated with a 12% increase in application to orthopaedics.¹⁶ Our study provided a strong correlation between an osteopathic medical school and ultimate orthopaedic residency training acceptance. Although out of the analytical scope of available data, the composition of colleges and schools of the osteopathic medical curriculum may provide more insight into many such considerations of osteopathic musculoskeletal education. 

Our study does recognize limitations. Our critical analysis of characteristics was limited to those captured within the AOA national database. Considering other facets of a candidate, there may be more inclusive factors to better paint the picture of the osteopathic orthopaedic residency class not captured in the study. Additional diversity trends not available for this study’s analysis will, in the future, improve more comprehensive characteristic composition within the orthopaedic surgical workforce. Also, our study considered only osteopathic medical schools collected within the AOA database with ultimate findings of strong correlation in matching into osteopathic orthopaedic residency. Other factors influencing candidate ranking and ultimate residency placement, if not captured within the AOA database, could not be evaluated in trends analysis due to limitations in available data. While a residency program’s location has a significant impact on where medical students apply, interview, and rate programs, with the fluid evolution of programs and within healthcare network systems engaging in medical education, further complex investigation on this regard for the future could be of consideration into distinct regional locations for potential geographic trends. Finally, there may have been osteopathic medical students conversely accepted into allopathic programs which also would not have been accounted for within the AOA database. Despite the limitations, the dataset was the most accurate combination of characteristics available for osteopathic orthopaedic residency programs in the USA. Furthermore, it will prove helpful in understanding the future of the orthopaedic workforce, particularly for application and faculty within the osteopathic profession. 

Conclusion
In conclusion, the findings of this study confirm that orthopaedic residency programs continue to train excellent osteopathic medical students with various characteristics. Even though there has been a minimal change over the past ten years of female composition in osteopathic orthopaedic residency composition with relatively stable percent composition, this is generally similar to allopathic counterparts. In addition, the age of residents at graduation decreased over the past decade. At the same time, osteopathic medical school training served as the most significant predicting factor in matching into osteopathic orthopaedic surgery. With these findings, attention can be aimed at mindfulness to provide greater exposure during medical school and increase the number of female faculty while maintaining an environment of quality orthopaedic residency programs.

Acknowledgments
The authors would like to thank Sharon McGill, Maura Biszewski, and the staff at the AOA, who greatly aided us in our data collection efforts. 

References

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