A study appearing in the Nov. 1 issue of the Journal of the AAOS explores why members of racial and ethnic minority groups have a lower rate of acceptance into orthopaedic residency programs, resulting in relative underrepresentation in such programs. The study reveals that less than 50 percent of applicants from black or Hispanic backgrounds actually enroll in residencies, whereas 69 percent of Asian and 73 percent of white applicants are accepted and matriculate into orthopaedic residencies. Minorities comprised 29 percent of applicants and 25 percent of enrolled candidates.
Those percentages represent averages over the 10-year study period, during which the authors analyzed data on 8,966 applicants from U.S. medical schools for orthopaedic residency and compared outcomes among racial/ethnic groups characterized as white, Asian, black, Hispanic, and other. (Because of lower overall enrollment rates into orthopaedic residencies, applicants with medical school type of Foreign Medical Graduate [n = 1,008], International Medical Graduate [n = 1,341], and Doctor of Osteopathic Medicine [n = 776], as well as those whose medical school type was not indicated [n = 2], were excluded from the original group of 12,093.) Quantitative factors used to assess applicants’ academic indicators (United States Medical Licensing Exam [USMLE] Step 1 and 2 Clinical Knowledge [CK] scores, number of publications, Alpha Omega Alpha [AOA] Honor Medical Society status, and volunteer experiences) were then broken down based on racial/ethnic group.
Looking for answers
The article noted that orthopaedic surgery residency programs have the lowest representation of racial/ethnic minorities among medical specialties.
Senior author Nadeen O. Chahine, PhD, of Columbia University, and first author Selina Poon, MD, MPH, of Shriners for Children Medical Center in Pasadena, Calif., commented in a joint statement that they undertook the study because, “Looking around us, it is clear that orthopaedic surgery lacks diversity. Residency programs also have low numbers of underrepresented minorities (URMs) among their ranks. We wanted to ask the question of whether differences in residency applicant metrics exist between applicants from different racial/ethnic groups that could partially explain this phenomenon.”
In addition to the basic finding that minorities are underrepresented in residency programs, “The second significant finding is that differences exist in the academic measures within the orthopaedic surgery applicant pool based on race/ethnicity,” the authors said. “White and Asian applicants and matriculated candidates had higher Step 1 scores compared [to] their counterparts. White applicants and matriculated candidates had higher Step 2 CK scores and were more likely to have AOA status than URMs. Hispanic enrolled candidates had a greater number of publications. Black applicants had more volunteer experiences than any other group.”
Another salient and disappointing finding, they said, was that, “The enrollment rates haven’t budged in 10 years, and the disparity in enrollment appears to be getting worse (data suggest bigger differences in 2015 compared to 2005) (Fig 1). It was eye-opening to see how few URMs were added to the specialty in the 10-year study period. From our results, you see that we only enrolled 238 black residents and 110 Hispanic residents in 10 years. That means a total of 348 URMs became orthopaedic surgeons in 10 years. That is extremely low compared to the 6,000-plus total number of orthopaedic surgeons joining the specialty in the same time period.”
Drs. Chahine and Poon said they now plan to assess how the academic variables they analyzed contribute to the odds of a student enrolling in orthopaedic surgery residency, taking into account both race and sex.
Improving the process to foster diversity
The authors said they hoped their findings would assist residency program directors in efforts to increase minority enrollment. “They can now look at each variable and determine how much weight to attribute to it based on the study. We found the biggest differences in metrics to be in Step 1 and AOA. While medical schools and other mentoring/training programs are going above and beyond to provide mentored research experiences for orthopaedics-bound medical students, it warrants taking another look at what can be done to strengthen student academic performance, especially on Step 1 exams. While applicants from underrepresented groups had more publications and volunteer experiences, that was not enough to push up residency enrollment.”
Additionally, they said, “Our data suggest that the practice of setting Step score thresholds for identifying candidates to interview does a disservice as far as diversity is concerned. Perhaps screening candidates based on the totality of the application would improve these trends. This does mean more work for the residency review committee, but finding and training the best future orthopaedic surgeon is a task that is worth the extra effort.”
They noted that other studies have shown that the Medical College Admission Test and the USMLE Step 1 and 2 have unexplained sex and racial/ethnic differences. “Although the test questions are not biased, there may be social factors involved. The USMLE tests are not designed to predict success in residency or even board passage rates. The multitude of other characteristics that make up a good resident/orthopaedic surgeon, such as the ability to perform in a team, empathy, professionalism, etc., are not available through test scores. We do not have the perfect metric to find the perfect resident yet. Clerkship evaluations and medical school grades may provide a better picture of the applicant.”
Limitations of the study, the authors said, include that the enrolled resident data were from the GME Track Resident Survey, which has a response rate among programs of 79.0 percent to 94.5 percent and therefore does not represent the entire orthopaedic residency population. Also, they said, “We were only able to evaluate the academic metrics available through the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME), which do not include the nuanced variables that contribute to the strength of an applicant and how they fit into a residency program. Also, other factors such as conscious or unconscious bias, which may contribute, were not evaluated in this study.”
The authors said they wish to express their appreciation for the dataset provided by AAMC and NBME: “These questions have lingered for a long time. Access to such data is a necessary step for getting clarity on where we are as a professional community.”
Drs. Chahine and Poon’s coauthors of “Underrepresented Minority Applicants Are Competitive for Orthopaedic Surgery Residency Programs, but Enter Residency at Lower Rates” are Kate Nellans, MD, MPH; Alyssa Rothman, MD; Rocio A.L. Crabb, MD; Stephen F. Wendolowski, MS; Daniel Kiridly, MD; Rachel Gecelter, MS; and Prakash Gorroochurn, PhD.
Source: Poon S, Nellans K, Rothman A, et al: Underrepresented minority applicants are competitive for orthopaedic surgery residency programs, but enter residency at lower rates. J Am Acad Orthop Surg 2019;27:e957-68.
Terry Stanton is the senior science writer for AAOS Now. He can be reached at email@example.com.