Orthopaedic surgery has consistently remained one of the least diverse specialties in medicine. In 2017, women surpassed men to comprise more than 50% of medical school matriculants; however, despite increasingly large numbers of qualified female medical students, only 16.7% of US orthopaedic surgery residents are women and only 6.5% of practicing orthopaedic surgeons are women.1–3

The number of female applicants to orthopaedic residency has been reported and is used to guide efforts to improve sex diversity. However, the match rate and subspecialty choice of female applicants to orthopaedic fellowship have only recently become topics of investigation.4,5

Cannada first published on sex and orthopaedic fellowship match in 2016. It was found that women comprised 7% to 10% of orthopaedic fellowship applicants from 2010 to 2014. The article reported that women were more likely to successfully match than men, with 96% of women successfully matching into fellowship over the 5-year period as compared with 81% of men. Pediatrics and foot and ankle had the highest number of female applicants while spine had the lowest number of female applicants.4

Fellowship has become the norm for orthopaedic residents, with more than 90% of residents pursuing fellowship training.4,6,7 This year of subspecialty training, while optional for many jobs, is frequently indicated for academic surgeons who will educate and mentor residents and medical students. Studies have shown that gender-congruent mentors and role models for female medical students and residents can strongly influence their career decisions.8,9 Therefore, improving sex diversity among fellowship training programs is an important step in improving sex diversity among orthopaedic surgeons. As we focus efforts on improving diversity, it is important to investigate what role, if any, sex may play in fellowship match.

The purpose of this study was to determine (1) how the percentage of women applying to orthopaedic fellowships has changed from 2011 to 2021, (2) whether there was a correlation between sex and the likelihood of a successful fellowship match, and (3) which subspecialties tend to have a greater proportion of female applicants and fellows.

Methods

Orthopaedic fellowship applicant data from 2011 to 2021 were obtained from San Francisco (SF) Match, a US-based matching service currently used by all orthopaedic fellowships (except hand fellowship). Applicants who were international medical school graduates (IMGs) and applicants who did not submit a rank list were excluded from the data analysis. If an applicant applied to more than one subspecialty, they were considered a unique applicant for each subspecialty match.

The subspecialties included were shoulder and elbow (SE), trauma, adult reconstruction, pediatrics, foot and ankle, sports, spine, and oncology. The SE fellowship match did not use SF Match until 2017; therefore, SE data were available only from 2017 to 2021. Until 2018, orthopaedic oncology fellowships were combined with adult reconstruction. Therefore, the exact number of oncology applicants was not possible to determine before 2019.

Sex was not recorded by SF Match until 2015. Therefore, the determination of sex before 2015 was done manually based on first name. If the name of the applicant was ambiguous, the physician's name was searched online and sex was determined based on pronouns used in online biographies. The number of female applicants and matches was recorded by year and compared with the number of male applicants and matches.

The data were compiled and analyzed by year and subspecialty to determine the number of applicants from each sex and their match rate. Fisher exact analysis was used to analyze categorical values. Significance was set at P < 0.05.

Results

During the study period, there were 6969 applicants identified for all orthopaedic specialties within SF Match: 859 were female (12.3%), and 6110 were male (87.7%; Figure 1). While the number of female applicants almost doubled over the 10-year period from 65 applicants (13.0%) in 2011 to 111 (14.4%) in 2021, the overall proportion of female applicants remained unchanged (P > 0.05).

Figure 1:

Bar graph representing the total number of orthopaedic fellowship applicants per year by sex.

The annual match rate was 90.8% to 100% for female applicants and 93.7% to 97.3% for male applicants (Figure 2). No statistically significant difference was observed in the match rate between male and female applicants at any time point.

Figure 2:

Line graph representing the annual San Francisco Match rate per year by sex.

The number of female applicants for each subspecialty is listed in Table 1. Pediatrics (30.0% to 46.2%), foot and ankle (9.8% to 26.0%), and oncology (21.4% to 37.5%) had the highest proportion of women within their applicant pools (Figure 3). Shoulder and elbow female applicants ranged from 3.4% to 14.3%, sports female applicants ranged from 7.4% to 13.0%, and trauma female applicants ranged from 5.1% to 25.3%. Adult reconstruction (3.9 to 9.0%) and spine (3.2% to 10.9%) had the lowest proportion of female applicants.

Table 1 - Total Female Fellowship Applicants Per Year for Each Orthopaedic Subspecialty Specialty Pediatrics Foot and Ankle Shoulder and Elbow Sports Trauma Adult Reconstruction Spine Oncology Year FA/TA % FA/TA % FA/TA % FA/TA % FA/TA % FA/TA % FA/TA % FA/TA % 2011 15/39 39 12/56 21 19/184 10 8/66 12 6/102 6 5/53 9 2012 18/39 46 8/57 14 21/197 11 17/68 25 7/96 7 4/67 6 2013 14/44 32 5/51 10 16/188 9 9/76 12 10/136 7 3/69 4 2014 24/57 42 10/66 15 20/170 12 10/74 14 9/137 7 3/82 4 2015 17/47 36 14/53 26 15/202 7 5/55 9 11/162 7 5/79 6 2016 18/45 40 10/53 19 23/177 13 16.83 19 11/170 7 3/93 3 2017 15/50 30 11/56 20 1/29 3 23/186 12 4/79 5 13/192 7 7/82 9 2018 21/48 44 14/54 26 3/27 11 20/192 10 9/85 11 13/173 8 5/199 4 2019 19/45 42 10/47 21 3/37 8 19/201 9 15/76 20 7/180 4 6/108 6 3/14 21 2020 13/43 30 13/50 26 2/32 6 17/190 9 15/95 16 14/205 7 6/101 6 6/16 38 2021 18/51 35 8/47 17 5/35 14 23/202 11 20/79 25 19/212 9 14/129 11 4/16 25

FA = female applicants, TA = total applicants.

Figure 3:

Line graph showing the percentage of matched positions held by women per year by subspecialty. No subspecialty changed significantly during this study period.

From 2011 to 2021, there was no statistically significant increase in the number of female applicants in pediatrics (P = 0.83), foot and ankle (P = 0.62), sports (P = 0.75), trauma (P = 0.06), adult reconstruction (P = 0.38), and spine (P = 1.0) fellowships. No statistically significant increase was observed in the number of female applicants for SE (P = 0.21) or oncology (P = 1.0) from when they joined SF Match to the end of the study period.

Discussion

This study analyzed 10 years of orthopaedic fellowship match data. It represents the longest and most comprehensive investigation into orthopaedic fellowship match and sex. Our study found that, despite increasing numbers of female applicants, there was no difference in the percentage of women applying to orthopaedic fellowships from 2011 to 2021.

In addition, our study found no difference in match rates between male and female applicants. This finding differs from the 2016 study by Cannada4, which found that women were markedly more likely to have a successful match than their male counterparts. While the present study and her original study both used data from SF Match, this study did not include hand applicants, nor did it include shoulder/elbow applicants from 2011 to 2016. In addition, our methods differed in that we chose to exclude IMGs, a population that tends to have a lower match rate and a higher proportion of men.

This study found that subspecialties such as spine and adult reconstruction have much lower proportions of women as previously noted in the literature. However, it cannot provide any definitive reasoning as to why women may be less likely to pursue these subspecialties.10–12 As suggested in a similar study by Lavorgna et al, the low sex diversity in these subspecialties can likely be due to the persistent and notable sex disparity in orthopaedic surgery resident programs.13 Few women residents lead to few women fellows which leads to few women attending surgeons and faculty; however, the consistent sex inconsistency between subspecialties is difficult to explicate.

Despite the differences in sex distribution among the subspecialties, there is no difference in match rate between the men and women who apply to them. This finding suggests that residents are not prevented from matching the specialty of their choice based on their sex. However, of important note, the societies with the lowest female membership participation, which parallels the fellowship applicant proportions, are those associated with adult reconstruction and spine.14 This may represent continued barriers that exist among female orthopaedic surgeons and, in turn, make it difficult for orthopaedic residents to find sex-matched mentors or seek leadership positions themselves.

Additional solutions have been offered by Trenchfield et al and Ajayi et al on this topic such as pipeline programs.11,15 Pipeline programs like Nth Dimensions and the Perry Initiative increase exposure to orthopaedics and mentorship availability within the field for underrepresented minorities and women. Studies have shown that sponsorship like the Ruth Jackson Orthopaedic Society scholarship to attend a national orthopaedic meeting, American Academy of Orthopaedic Surgeons, has proven to be successful with 80% of recipients being orthopaedic surgery residents or attendings. Programs and opportunities like these serve as a great source of recruitment at the medical student level which can feed into the resident and then fellow and eventually attending level.

There are limitations to this study. Sex was not recorded by SF Match until 2015, and manual assignment of sex by examination of the first name may have erroneously assigned the wrong sex. In addition, we recognize that sex is not binary, and therefore, our study inherently did not capture the full spectrum of representation. Hand subspecialty match is not included in SF Match, and given that hand typically has a higher percentage of female applicants and women who successfully match ranging from 20.7% to 30.7% from 2007 to 2021, it may have affected the overall number of female applicants and successful matches.10 However, the hand match also includes plastic surgery and general surgery applicants, and it is difficult to isolate orthopaedic resident applicants. Similarly, the spine match includes neurosurgical residents presenting a similar problem to the hand match. Finally, if an applicant applied to more than one subspecialty, they were considered a unique applicant—this may have underrepresented the match rate(s) presented in this study.

This study found that the percentage of female orthopaedic fellowship applicants has remained relatively unchanged in the past 10 years at ∼12%. The rate of successful fellowship match among male and female applicants did not differ during this 10-year period. The proportion of female fellows is not equally distributed among subspecialties, with a higher proportion of women applying and matching into pediatrics and foot and ankle and a markedly lower proportion in adult reconstruction and spine. These data provide a benchmark for department chairs and society leadership to ensure they are recruiting, interviewing, and hiring candidates who are representative of the current sex demographics of orthopaedic fellowship graduates.

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