Who Bears the Burden? Understanding the Socioeconomic Patterns of Educational Debt in Orthopaedic Surgery Residency Candidates.

BACKGROUND: Educational debt is commonly observed among applicants to orthopaedic surgery residency programs; however, an understanding of the debt burden among minority and nonminority applicants is not well established. Thus, this study aimed to fill these knowledge gaps by examining the extent of and factors shaping educational debt among orthopaedic surgery applicants. QUESTIONS/PURPOSES: (1) What is the educational debt burden among orthopaedic surgery residency applicants? (2) After controlling for relevant confounding variables, what factors are independently associated with increasing levels of educational debt? (3) After controlling for relevant confounding variables, are individuals classified as an underrepresented minority or those with educational debt and socioeconomic disadvantage less likely to match in orthopaedic surgery? METHODS: A retrospective evaluation of orthopaedic surgery residency application data from the American Association of Medical Colleges was analyzed from 2011 to 2021. The American Association of Medical Colleges database was selected because every residency applicant must register and apply through the American Association of Medical Colleges. Therefore, these data exist for every residency applicant, and the sample was comprehensive. Self-reported data including premedical, medical, and total educational debt burden as well as classification as socioeconomically disadvantaged and application fee waiver use were collected. Applicants were dichotomously categorized as an underrepresented minority or a not underrepresented minority based upon self-identified race and ethnicity. Monetary values were reported in USD and inflation-adjusted to 2021 using the Consumer Price Index. We performed t-tests and chi-square tests for continuous and categorical variables, respectively. Significance was considered at p < 0.05. In all, 12,112 applicants were available in the initial cohort, and 67% (8170 of 12,112) of applicants with complete data were included from 2011 to 2021 in the final study cohort. Of these, 18% (1510 of 8170) were women, 14% (1114 of 8170) were classified as underrepresented minorities, and 8% (643 of 8170) were classified as socioeconomically disadvantaged. Sixty-one percent (4969 of 8170) of applicants reported receiving at least one scholarship, 34% (2746 of 8170) had premedical school debt, and 72% (5909 of 8170) had any educational debt including medical school. Among all applicants, the median (IQR) educational debt was USD 197,000 (25,000 to 288,000). Among those with scholarships, the median amount was USD 25,000 (9000 to 86,000). RESULTS: After controlling for the potentially confounding variables of gender and socioeconomic disadvantage, classification as an underrepresented minority applicant was independently associated with higher scholarship amounts than applicants characterized as not underrepresented minorities (ß = USD 20,908 [95% confidence interval (CI) 15,395 to 26,422]; p < 0.001), whereas underrepresented minority classification was not independently associated with a difference in total educational debt (ß = USD 3719 [95% CI -6458 to 13,895]; p = 0.47). After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with higher scholarship amounts (ß = USD 20,341 [95% CI 13,300 to 27,382]; p < 0.001) and higher total educational debt (ß = USD 66,162 [95% CI 53,318 to 79,006]; p < 0.001) than applicants not classified as socioeconomically disadvantaged. After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with decreased match rates (OR 0.62 [95% CI 0.52 to 0.74]; p < 0.001). CONCLUSION: These findings underscore the need for comprehensive scholarship initiatives to ensure equitable financial accessibility for applicants from all backgrounds. CLINICAL RELEVANCE: In the future, orthopaedic surgery may benefit from research comparing the effectiveness of various initiatives aiming to improve fairness in the burden of debt among applicants to orthopaedic surgery residency programs.

Very Few ACGME-accredited Orthopaedic Surgery Residency Programs Have Web-accessible Leave Policies Dedicated to Parental Leave for Residents, Despite ACGME Requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires that all graduate medical education (GME) programs provide at least 6 paid weeks off for medical, parental, and caregiver leave to residents. However, it is unclear whether all orthopaedic residency programs have adapted to making specific parental leave policies web-accessible since the ACGME's mandate in 2022. This gap in policy knowledge leaves both prospective and current residents in the dark when it comes to choosing residency programs, and knowing what leave benefits they are entitled to when having children during training via birth, surrogacy, adoption, or legal guardianship. QUESTIONS/PURPOSES: (1) What percentage of ACGME-accredited orthopaedic surgery residency programs provide accessible parental leave policies on their program's website, their GME website, and through direct contact with their program's administration? (2) What percentage of programs offer specific parental leave policies, generic leave policies, or defer to the Family and Medical Leave Act (FMLA)? METHODS: As indicated in the American Medical Association's 2022 Freida Specialty Guide, 207 ACGME-accredited orthopaedic residency programs were listed. After further evaluation using previous literature's exclusion criteria, 37 programs were excluded based on osteopathic graduate rates. In all, 170 ACGME-accredited allopathic orthopaedic surgery residency programs were identified and included in this study. Three independent reviewers assessed each program website for the presence of an accessible parental leave policy. Each reviewer accessed the program's public webpage initially, and if no parental leave policy was available, they searched the institution's GME webpage. If no policy was found online, the program administrator was contacted directly via email and phone. Available leave policies were further classified into five categories by reviewers: parental leave, generic leave, deferred to FMLA, combination of parental and FMLA, and combination of parental and generic leave. RESULTS: Our results demonstrated that 6% (10 of 170) of orthopaedic residency programs had policy information available on their program's main orthopaedic web page. Fifty nine-percent (101 of 170) of orthopaedic residency programs had a clearly stated policy on their institution's GME website. The remaining 35% (59 of 170) had no information on their public website and required direct communication with program administration to obtain policy information. After directly contacting program administration, 12% (21 of 170) of programs responded to researchers request with a PDF explicitly outlining their policy. Twenty-two percent (38 of 170) of programs did not have an accessible policy available. Of the programs that had available policies, a total of 53% (70 of 132) of programs were categorized as offering explicit parental leave policies, 9% (12 of 132) were categorized as offering general leave policies, and 27% (36 of 132) deferred to FMLA. Seven percent (9 of 132) offered combined parental leave policies with FMLA, and 4% (5 of 132) offered combined general leave policies with FMLA. CONCLUSION: Although most ACGME-accredited allopathic orthopaedic surgery residency programs met the ACGME requirement of written parental leave policies in 2023, a small minority of programs have clear, accessible parental leave policies provided on their webpage. CLINICAL RELEVANCE: Parental leave policies should be easily accessible to prospective and current trainees and should clearly state compensation and length of leave. Ensuring orthopaedic surgery residency programs provide accessible and transparent parental leave policies is important for maintaining diversity in prospective applicants and supporting the work-life balance of current residents.

Correlation between research productivity during and after orthopaedic surgery training.

Background: Research experience is mandatory for all Orthopaedic Surgery residency programs. Although the allocation of required protected time and resources varies from program to program, the underlying importance of research remains consistent with mutual benefit to both residents and the program and faculty. Authorship and publications have become the standard metric used to evaluate academic success. This study aimed to determine if there is a correlation between the research productivity of Orthopaedic Surgery trainees and their subsequent research productivity as attending Orthopaedic Surgeons. Methods: Using the University of Mississippi Orthopaedic Residency Program Research Productivity Rank List, 30 different Orthopaedic Surgery Residency Programs were analyzed for the names of every graduating surgeon in their 2013 class. PubMed Central was used to screen all 156 physicians and collect all publications produced by them between 2008 and August 2022. Results were separated into two categories: Publications during training and Publications post-training. Results: As defined above, 156 Surgeons were analyzed for publications during training and post-training. The mean number of publications was 7.02 ± 17.819 post-training vs. 2.47 ± 4.313 during training, P < 0.001. The range of publication post-training was 0-124 vs. 0-30 during training. Pearson correlation between the two groups resulted in a value of 0.654, P < 0.001. Conclusion: Higher research productivity while training correlates to higher productivity post-training, but overall Orthopaedic surgeons produce more research after training than during. With the growing importance of research, more mentorship, time, and resources must be dedicated to research to instill and foster greater participation while in training.

Sex Disparities Among Fellowship Program Directors in Orthopaedic Surgery.

BACKGROUND: Women are underrepresented in the orthopaedic surgery workforce in the U.S. The purpose of this study was to elucidate the representation of women among fellowship program directors (PDs) in orthopaedic surgery. METHODS: This was a retrospective cohort study of fellowship PDs in orthopaedic surgery during the 2022 to 2023 academic year. Academic, training, and demographic characteristics were collected from internet-based resources. Participation-to-prevalence ratios (PPRs) were calculated for both men and women. A PPR of <0.8 indicated underrepresentation and a PPR of >1.2 indicated overrepresentation. Bivariate analyses were utilized to assess the correlation between sex diversity and geographic region and between sex diversity and Accreditation Council for Graduate Medical Education (ACGME)-accreditation status. The relationship between the median annual salary and the sex diversity of each orthopaedic subspecialty was analyzed with use of the Pearson correlation coefficient. RESULTS: This study included 600 fellowship PDs, 40 (6.7%) of whom were women. In total, 24.5% of the fellowship PDs were assistant professors (8.8% women versus 91.2% men, p < 0.001); 26.2% were associate professors (9.6% women versus 90.4% men, p < 0.001); 36.8% were full professors (4.5% women versus 95.5% men, p < 0.001); and 12.5% were unranked (2.7% women versus 97.3% men, p < 0.001). The representation of women increased with academic rank, as reflected in their prevalence at the assistant (PPR = 0.67), associate (PPR = 0.77), and full professor (PPR = 0.80) levels. Among the orthopaedic subspecialties, musculoskeletal oncology (19.0%), pediatric orthopaedics (14.6%), and hand surgery (12.6%) had the highest proportions of women fellowship PDs. PPRs were lowest for orthopaedic sports medicine (PPR = 0.35), shoulder and elbow (PPR = 0.45), and adult reconstruction (PPR = 0.52). Women PDs had equitable representation in musculoskeletal oncology (PPR = 1.17), hand surgery (PPR = 1.02), foot and ankle (PPR = 0.84), and orthopaedic trauma (PPR = 0.80). Median subspecialty compensation was negatively correlated with the prevalence of women among fellowship PDs (r = -0.70, p = 0.036). Geographic region was not associated with sex diversity (p = 0.434), but programs with ACGME accreditation had significantly more women fellowship PDs than those without (11.0% versus 3.9%, p < 0.001). CONCLUSIONS: Women are underrepresented among orthopaedic fellowship PDs, especially in certain subspecialties (orthopaedic sports medicine, shoulder and elbow, and adult reconstruction). More research is needed to understand the barriers that impact the representation of women among leadership positions in orthopaedic surgery. CLINICAL RELEVANCE: Greater sex diversity among fellowship PDs may help to increase the recruitment of women into orthopaedic subspecialties. The equitable consideration of orthopaedic surgeons from all backgrounds for leadership positions can increase workforce diversity, which may improve the vitality of the orthopaedic community.

Accessibility and Characterization of Parental Leave Policies for Orthopaedic Surgery Residency Training in the United States.

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.

Preference Signaling Survey of Program Directors-After the Match.

INTRODUCTION: The 2022 to 2023 orthopaedic residency cycle implemented a preference signaling program (PSP), allowing applicants to send "signals" to up to 30 programs to demonstrate their genuine interest. With the conclusion of the 2022 to 2023 cycle, the primary purpose of this study was to analyze program director (PD) perceptions of the PSP after the match cycle and provide a retrospective evaluation of the effects of the PSP on the orthopaedic resident selection process. METHODS: A 21-question survey was distributed to 98 PDs (32.7% response rate). Contact information was obtained from a national database. RESULTS: Most respondents (96.9%) participated in the American Orthopaedic Association's PSP. The majority (93.7%) view preference signaling as a positive change. Most PDs (56.2%) reported a decreased number in applications received compared with previous years. Receiving a preference signal was ranked among the most important factors in resident selection, and most PDs agreed that preference signaling should be used to screen applicants (84.4%) and differentiate similar applicants (96.8%). Moreover, 65.6% of PDs indicated that they would not rank or invite applicants to interview without a signal or completion of a formal away rotation. PDs report that in the 2022 to 2023 cycle, 98.5% of applicants who matched at their program had sent a preference signal. DISCUSSION: Preference signaling was one of the most important factors assessed during its inaugural application cycle and is anticipated to remain a key tool for screening and differentiating candidates. Applicants should strategically select signal recipients to enhance their success in the match.

Perspectives on Application and Interview Capping in Residency Selection of Surgical Subspecialties.

OBJECTIVE: With the advent of virtual interviews, the potential for interview hoarding by applicants became of greater concern due to lack of financial constraints associated with in-person interviewing. Simultaneously, the average number of applications submitted each year is rising. Currently there is no cap to the number of applications or interviews an applicant may complete when applying to residency, with the exception of ophthalmology with a cap of 15 interviews. No studies have assessed the applicants' perspectives on an application or interview cap. We assessed the attitudes of surgical subspecialty applicants towards capping, which may be useful when considering innovations in residency selection. DESIGN/SETTING/PARTICIPANTS: About 1841 applicants to the Johns Hopkins' ophthalmology, urology, plastic surgery, and orthopedic surgery residency programs from the 2022-2023 cycle were invited to respond to a 22-item questionnaire. Statistical analyses of aggregate data were conducted using R. RESULTS: Of the 776/1841 (42%) responses, 288 (40%) were in support of an application cap, while 455 (63%) were in support of an interview cap. Specialty (p < 0.001), gender (p < 0.001), taking a gap year (p = 0.02), medical school region (p = 0.04), and number of interviews accepted off of a waitlist (p = 0.01) were all significantly associated with a difference in opinion regarding an application cap. Specialty (p < 0.001), USMLE Step 1 score (p = 0.004), number of interviews (p < 0.001), and number of programs ranked (p < 0.001) were all significantly associated with a difference in opinion regarding an interview cap. Of those applicants who were in support of the respective caps they believed that on average a cap should consist of 48.1 (16.1) applications and 16.0 (8.0) interviews. CONCLUSIONS: Our findings highlight the desire for interview caps among the majority of applicants to surgical subspecialties and thus this innovation may be considered by other specialties in the era of virtual interviews.

Sex Diversity and Equity Among Fellows of the American Orthopaedic Association.

BACKGROUND: We hypothesized that women are underrepresented among fellows of the American Orthopaedic Association (AOA) relative to their prevalence among faculty at departments of orthopaedic surgery. METHODS: Clinical faculty at departments of orthopaedic surgery that are affiliated with residency training programs were analyzed for AOA membership. Participation-to-prevalence ratios (PPRs) were calculated for men and women with AOA membership relative to their prevalence among orthopaedic surgeon faculty. A PPR of <0.8 or >1.2 indicated under- or overrepresentation, respectively. PPR values between 0.8 and 1.2 indicated equivalent representation. Sex disparities in AOA membership were explored by academic rank and orthopaedic subspecialty. RESULTS: There were 4,310 orthopaedic surgery faculty, and 998 (23.2%) had AOA membership. Overall, women formed the minority of members in the AOA study cohort (11.4%), but they had equivalent representation relative to their prevalence among faculty (10.0%, PPR = 1.14, p = 0.210). In the AOA study cohort, women were the minority at each academic rank, including assistant professor (20.2% versus 79.8%, p < 0.001), associate professor (16.8% versus 83.2%, p < 0.001), and full professor (7.0% versus 93.0%, p < 0.001). However, women had greater representation in the AOA study cohort at each academic rank than would be expected based on their prevalence among faculty, including the assistant (PPR = 1.45), associate (PPR = 1.56), and full (PPR = 1.27) professor levels. Similarly, in the AOA study cohort, women were the minority in each orthopaedic subspecialty, but were only underrepresented in pediatric orthopaedics (PPR = 0.74). Women had greater representation in the AOA study cohort than would be expected by their prevalence among faculty in hand surgery (PPR = 1.51) and orthopaedic sports medicine (PPR = 1.33). In contrast, men had equivalent representation in each orthopaedic subspecialty. CONCLUSIONS: Women form a minority group in the AOA, but they exhibit greater representation in the AOA than would be expected based on their prevalence among faculty at each academic rank, and they have greater representation than men, who exhibit equivalent representation across all academic ranks. Collectively, these results disproved our hypothesis, and suggest that women are participating in the AOA at rates that are greater than their prevalence among faculty. CLINICAL RELEVANCE: Equitable participation of women in orthopaedic surgery is necessary to promote diversity and inclusion in the specialty. The AOA may be an important catalyst for future positive diversity and inclusion efforts within orthopaedic surgery.

Identification of Factors Associated with Orthopaedic Surgery Residency Programs That Preferentially Match Students Who Performed an Elective Rotation Before the Interview Process.

Introduction: The role of elective rotations in the orthopaedic residency selection process varies between programs. Our study aims to identify factors associated with residency programs that interview and match a greater proportion of applicants who have completed an elective rotation with their program. Methods: Data were collected through the American Orthopaedic Association's Orthopaedic Residency Information Network database. Bivariate correlations and multivariate regression models were used to identify independent predictors of programs with a greater proportion of interviewees or residents who completed an elective rotation at the respective program. Results: One hundred seventy-eight of the 218 existing residency programs were included in this study. Programs that offered fewer interviews and more away rotation positions per year were associated with a greater odds of its interviewees (OR = 0.36, p = 0.01; OR = 4.55, p < 0.001, respectively) and residents (OR = 0.44, p = 0.04; OR = 4.23, p < 0.001, respectively) having completed an elective rotation with the program. In addition, programs with fewer attendings (OR = 0.39, p = 0.03) and in-person interviews (OR = 3.04, p = 0.04) matched a greater proportion of their rotators. However, programs that interviewed applicants during the elective rotation were less likely to match their rotators (OR = 0.35, p = 0.04). Conclusion: Certain program characteristics independently predict the likelihood of a program interviewing and matching their rotators. These findings may provide information for applicants and programs regarding the rotation process. Level of Evidence: III.

Endoscopic Versus Open Treatment of Carpal Tunnel Syndrome: Postoperative Complications in Patients With Diabetes Mellitus.

Purpose: Patients with type 2 diabetes mellitus (T2DM) often face higher postoperative complication rates. Limited data exist regarding outcomes in T2DM patients undergoing carpal tunnel release (CTR). This study compares complication rates between endoscopic CTR (ECTR) and open CTR (OCTR) in patients with T2DM. Methods: The TriNetX database was used to perform a retrospective cohort study of 67,225 patients with T2DM who underwent ECTR (n = 17,792) or OCTR (n = 49,433). Demographic data, medical comorbidities, and complication rates were analyzed. A 1:1 propensity score match was performed to calculate risk ratios and 95% confidence intervals of postoperative median nerve injury, 6-week wound dehiscence, and 6-week wound infection. Results: After matching, a significantly greater number of ECTR patients had liver disease (P = <.001) and a body mass index > 40 (P = .001) compared to the OCTR group. These patients also had a lower incidence of fluid and electrolyte disorders (P = .003). Patients with T2DM who underwent ECTR had a significantly lower relative risk of 6-week wound infection, 6-week wound dehiscence, and median nerve injury (all P < .001) compared to patients who underwent OCTR. Conclusions: In our analysis of T2DM patients undergoing CTR, ECTR yielded significantly lower rates of wound infection, wound dehiscence, and nerve injury within 6-weeks post-surgery, reducing the risk by 43%, 52%, and 58%, respectively. These findings suggest that ECTR may result in a lower complication rate in this patient population. Type of study/level of evidence: III.

ChatGPT Performs at the Level of a Third-Year Orthopaedic Surgery Resident on the Orthopaedic In-Training Examination.

Introduction: Publicly available AI language models such as ChatGPT have demonstrated utility in text generation and even problem-solving when provided with clear instructions. Amidst this transformative shift, the aim of this study is to assess ChatGPT's performance on the orthopaedic surgery in-training examination (OITE). Methods: All 213 OITE 2021 web-based questions were retrieved from the AAOS-ResStudy website (https://www.aaos.org/education/examinations/ResStudy). Two independent reviewers copied and pasted the questions and response options into ChatGPT Plus (version 4.0) and recorded the generated answers. All media-containing questions were flagged and carefully examined. Twelve OITE media-containing questions that relied purely on images (clinical pictures, radiographs, MRIs, CT scans) and could not be rationalized from the clinical presentation were excluded. Cohen's Kappa coefficient was used to examine the agreement of ChatGPT-generated responses between reviewers. Descriptive statistics were used to summarize the performance (% correct) of ChatGPT Plus. The 2021 norm table was used to compare ChatGPT Plus' performance on the OITE to national orthopaedic surgery residents in that same year. Results: A total of 201 questions were evaluated by ChatGPT Plus. Excellent agreement was observed between raters for the 201 ChatGPT-generated responses, with a Cohen's Kappa coefficient of 0.947. 45.8% (92/201) were media-containing questions. ChatGPT had an average overall score of 61.2% (123/201). Its score was 64.2% (70/109) on non-media questions. When compared to the performance of all national orthopaedic surgery residents in 2021, ChatGPT Plus performed at the level of an average PGY3. Discussion: ChatGPT Plus is able to pass the OITE with an overall score of 61.2%, ranking at the level of a third-year orthopaedic surgery resident. It provided logical reasoning and justifications that may help residents improve their understanding of OITE cases and general orthopaedic principles. Further studies are still needed to examine their efficacy and impact on long-term learning and OITE/ABOS performance.