Orthopaedic residency programs lack gender and race diversity.
Approximately one-half of the population of the United States is female, and
approximately one-quarter comprises African Americans, Native Americans, and
Latinos. Nonetheless, orthopaedic residencies do not come close to matching
these national
norms1,2.
The present study examines the premise that the number of women and
underrepresented minorities who choose orthopaedic surgery as a career may be
increased by increasing the required exposure of such students to
musculoskeletal instruction in medical school. Specifically, we tested the
hypothesis that the presence of a required course in musculoskeletal medicine
in medical school is associated with a higher rate of application to
orthopaedic surgery residency programs by the underrepresented groups.
The goal of ensuring that all American medical schools require instruction
in musculoskeletal medicine in their curriculum can be justified on many
grounds3-5.
Enhancing the diversity of orthopaedic surgery residency programs may be yet
another benefit of such an effort.
In 2002, there were 16,294 American medical school graduates, of whom
approximately 8945 (55%) had mandatory instruction in musculoskeletal
medicine. (The reason that this number is given only as an approximation is
discussed below.)
A total of 881 American medical students applied to orthopaedic surgery
residencies by means of the Electronic Residency Application Service. Thus,
the rate of application among all students was 5.4%
(Table I). Among students who
graduated from a school with required instruction, the rate was 5.7%. The rate
of application to orthopaedic surgery residency programs among students who
graduated from a school with no required instruction, by contrast, was 5.1% (p
= 0.090).
Of the 16,294 graduates of American medical schools, 8473 (52%) were women
(Table II). The overall rate of
application to orthopaedic surgery residency programs for female graduates was
1.5%. Of the 3175 women who graduated from a school with required instruction,
sixty-three applied to orthopaedic surgery residency programs, yielding a rate
of 2.0%. The rate of application to orthopaedic surgery residency programs
among the 5298 female students who graduated from a school with no required
instruction was 1.1% (p = 0.002).
A total of 1793 graduates (11%) of American medical schools were from an
underrepresented minority group (Table
III). The overall rate of application to orthopaedic surgery
residency programs among minority applicants was 6.7%. The rate of application
to orthopaedic surgery residency programs among minority applicants who
graduated from a school with required instruction was 8.2%. The rate of
application to orthopaedic surgery residency programs among minority
applicants who graduated from a school with no required instruction was 6.1%
(p = 0.095).
Required instruction in musculoskeletal medicine was associated with an
overall 12% higher rate of application to orthopaedic surgery residency
programs among all students (5.7% of those who had required courses compared
with 5.1% of those who did not). The difference in application rates was more
pronounced among women (2.0% compared with 1.1%, respectively; a 75% relative
difference) and minorities (8.2% compared with 6.1%, respectively; a 35%
relative difference). This study therefore suggests that required instruction
in musculoskeletal medicine can help to promote diversity in orthopaedic
surgery residency programs.
One limitation of this study is that these comparisons merely demonstrate
an association between required instruction and application to orthopaedic
surgery residency programs. They do not prove a cause-and-effect relationship,
and indeed inferring a relationship may not be justified. For instance, a
college student with an interest in orthopaedic surgery who applies to medical
school may choose to attend a given medical school on the basis of that
school's strong musculoskeletal curriculum. This is a self-selection bias. A
confounding effect may also be present. That is, schools with a talented
faculty in orthopaedic surgery may use that talent and require instruction in
musculoskeletal medicine. The talented faculty may also strongly attract
applicants to orthopaedic surgery residency. As such, the presence of a course
per se cannot be said to attract the applicants.
Another limitation is that the data on a medical school's curriculum may
imperfectly reflect the instruction at a given school. To be sure, the methods
of assessing curricula used previously made no attempt to ascertain anything
about quality. Furthermore, although the type and duration of instruction were
noted previously, all schools with any required instruction whatsoever were
considered comparable in this study. For instance, a school with a brief
clinical rotation in the fourth year would be granted the same credit as a
school that had an elaborate preclinical course and lengthy clinical rotation.
Needless to say, the latter likely would impact career choice more than a
brief senior-year exposure.
In addition, it is possible that a given graduate in 2002 was not exposed
to the curriculum that the previous survey attributed to his or her school.
That is because the student may have transferred from another school or may
have sought a second degree—beginning medical school perhaps as early as
1993—and therefore did not share the same course of study as the other
2002 graduates. From our experience, this is apt to be a small source of
error. It is, however, the main reason that we did not analyze the application
rate of MD/PhD students (the other "underrepresented" group). It
would be difficult to determine the courses to which these students were
exposed short of interviewing them.
Although this study describes the relative dearth of female and minority
applicants in orthopaedic surgery, the shortage of each is a problem of a
distinct type. Women are already adequately represented in the medical school
class; in 2002, in fact, the majority of medical school graduates were women.
Nonetheless, women are not applying to orthopaedic surgery in numbers
commensurate with their representation in the graduating class. Minorities, on
the other hand, represented only 11% of the graduating medical school
population but about 25% of the country's population. In addition, the rate of
applications from minority candidates to orthopaedic programs is not
disproportionately low; in fact, it is above average. Accordingly, the
absolute shortage of minorities in orthopaedic residency can be solved only
with increased recruitment to medical school, not by selective recruitment
within the medical school class. It can be argued that because orthopaedic
surgeons are among the few specialists with whom young people interact,
increasing the number of minority orthopaedic surgeons may assist with such a
generalized recruitment effort— thereby benefiting all fields.
It should be noted that, even if the rate of applications from schools
currently not requiring instruction were brought up to the level of
applications from schools that do require instruction, the problem of
inadequate diversity would not be not solved. Specifically, increasing the
rate of women and underrepresented minorities from schools without instruction
by 75% and 35%, respectively, would still augment the pool of applicants by
only forty-five women and twenty-seven underrepresented minority candidates.
In order to attain an applicant pool that is approximately 50% women and 25%
underrepresented minorities, an additional 650 female and 135 underrepresented
minority applicants would be required (assuming the number of male applicants
were to be held constant). In sum, required instruction in musculoskeletal
medicine may help to achieve diversity in orthopaedic surgery residency
programs but, in and of itself, is not sufficient.