Jessica Ng OMS IV, SAOAO¹; Ryan Johnson Data Scientist²; Ali Al Saeed³; Kyse Dahdal³; Maddison Messmer DO⁴; Brian Handal DO, RAOAO, Orthopedic Spine Fellow⁵; Julieanne P. Sees DO, MBA, FAOAO, FAOA, FAAOS Pediatric Orthopedic Surgeon, Fellow of Osteopathic Medicine^6
1Philadelphia College of Osteopathic Medicine – South Georgia
²Capitol Technology University
³Saint Xavier University
⁴Kettering Health Dayton Department of Orthopedic Surgery
⁵Florida Orthopedic Institute 
⁶National Academy of Medicine

Abstract

Background
Matching into orthopaedic surgery residency is highly competitive. Data are limited regarding characteristics in an applicant’s profile who successfully matched in the selection process. This study aimed to quantify trends in characteristics of osteopathic orthopaedic residents and changes within American Osteopathic Academy of Orthopedics (AOAO) distinctive workforce regarding their experiences before residency. 

Methods
A confidential optional online survey was distributed with questions aimed at identifying trends in the characteristics of osteopathic orthopaedic residents. Responses of Postgraduate Year (PGY) senior residents, defined as Current PGY 4-5’s in-training across 39 osteopathic orthopedic residency programs, were compared to Prior PGY’s, defined as active AOAO members and orthopaedic residency program directors. Results were analyzed, such as clinical experiences and/or gap year(s) prior to medical school; publications prior to residency; whether USMLE was taken, which Step(s) and what motivation; number of audition rotations/programs applied/interviews; and whether auditioned at matched residency. 

Results
Overall, 58 participants completed the survey, 87.9% males and 12.1% females, consisting of 93.1% White, 3.4% Black, 1.7% American Indian/Alaskan Native, and 1.7% two or more/mixed ethnicity. 22 participants were Current PGY’s with average age 32.8 years and 36 were Prior PGY’s with average age 50 years at time of survey. Of 38 responses, the most common clinical experience prior to medical school was medical technician/physical therapist (PT) at 31.6%. Of 30 responses, Current PGY’s averaged 1.2 gap years (12, range: 0-5 years) while Prior PGY’s averaged 1.3 years (18, range: 0-7 years). Prior to residency, the average number of publications for Current PGY’s was 3-4, whereas Prior PGY’s was 0-1.  Between the groups, the majority of participants did not take USMLE Step 1, and for those who did, the majority did not take USMLE Step 2. When asked why USMLE was taken 50% responded for their own personal interest or satisfaction, and 50% responded it was residency motivated. Between Prior and Current PGY’s, the average number of orthopaedic audition rotations increased by 1.5. Interestingly, 95.5% of Current PGY’s rotated at their matched orthopedics program, whereas 77.8% of Prior PGY’s rotated at their matched program. Prior PGY’s applied to an average of 11 residency programs (range: 1-30), while Current PGY’s submitted an average of 29 applications (range: 10-120). The average number of residency programs at which a participant interviewed only increased by 2, with Current PGY’s averaging 5 interviews (range: 2-10) and Prior PGYs averaging 3 (range: 1-11). 

Conclusions/ Discussion
Overall, there is a trend towards a more complex applicant, with a slight increase in publications and, most significantly, an increase in match success with an audition and interview at the ultimate residency program. With such knowledge, this provides insight into the growing AOAO residency membership, including a holistic approach to candidate selection which ultimately enhances the future of the orthopaedic workforce. 

Keywords: Osteopathic, Match, Orthopedic Surgery, Orthopaedic, Residency, Graduate Medical Education, Medical Student

Introduction
Orthopaedic surgery residency is one of the most highly competitive fields in which to match. Every year, thousands of medical student applicants apply for a limited number of residency positions. However, data are limited regarding the characteristics of successfully matched osteopathic orthopaedic surgery residents. With the field changing rapidly, from the 2020 transition of the American Osteopathic Association (AOA) and the American Council of Graduate Medical Education (ACGME) to form a single graduate medical education (GME) accreditation system to the movement of the United States Medical Licensing Examination (USMLE) and the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) going to pass or fail in 2022, the need for discrete quantization of resident characteristics is now more crucial than ever. Moreover, novel data regarding the characteristics of prior and current Doctor of Osteopathy (DO) residents in traditionally osteopathy orthopaedic residency programs proves advantageous for residency applicants and shaping the future of both medical education and the orthopaedic profession. 

According to 2022 data from the National Resident Matching Program (NRMP), there were 210 orthopedic surgery residency programs with a total of 875 PGY-1 positions available. A total of 1470 applicants applied, consisting of 205 osteopathic medical students/DO, 1,086 allopathic medical students/Medical Doctor (MD), and resulted in 80.6% of MD Seniors matched and 12.7% of DO Seniors matched, with 0 spots going unfilled (1). The burden on orthopaedic residency program applicants, especially DO applicants, to compete in this field continues to grow exponentially with each cycle. By examining the characteristics of successfully matched osteopathic orthopaedic residents, both prior and current with the membership of the national osteopathic orthopaedic academy of the AOAO, we can further explore what personal profile and experience lends to match into one of the most coveted specialties. In order to select the most holistic residents, many facets of a medical student’s application are commonly examined by orthopaedic residency programs. These often include prior experiences to medical school, including jobs and gap years, number of publications, choice of board examination(s), how many and where were audition rotations performed, and how many interviews were completed. Having no reports recorded in the literature, our current study aims to investigate the characteristics of a successfully matched osteopathic orthopaedic surgery resident’s profile. Our purpose is to quantify trends in characteristics of osteopathic orthopaedic residents and changes within the AOAO distinctive workforce regarding their experiences before residency.  

Methods
To understand the trends in the characteristics of matched osteopathic orthopedic residents, a confidential optional online survey was distributed to current PGY 4-5’s in training across 39 osteopathic orthopedic residency programs, active AOAO members and orthopaedic residency program directors. Active AOAO members, including orthopaedic residency program directors, are all orthopaedic surgeons who have completed an orthopaedic surgical residency after graduating from an accredited school/college of osteopathic medicine. The qualitative data collected included: clinical experiences and/or gap year(s) prior to medical school; publications prior to residency; whether the USMLE was taken, which Step(s) and the motivation behind taking the exam; the number of audition rotations/ programs applied/ interviews; and whether they auditioned at their matched residency. Responses of Current PGY’s, defined as PGY 4-5’s currently in-training, were compared to Prior PGY’s, defined as active AOAO members and program directors. Statistical analysis was performed with Google Sheets and included mean values, standard deviation, Pearson correlation coefficient, and interquartile ranges. This analysis was utilized to further evaluate categorical variables. 

Results
The survey yielded a total of 58 responses: 22 Current PGY’s and 36 Prior PGY’s. Of the total responses, 87.9% were males and 12.1% were females with a distribution of 93.1% were White, 3.4% were Black, 1.7% were American Indian/Alaskan Native, and 1.7% were two or more/mixed ethnicity (Figure 1,2). At the time of the survey, Current PGY’s had a mean age of 32.8 ± 3.0 years, and Prior PGY’s had a mean age of 50.9  ± 13.0 years. 

Between both groups (n=38), when asked what the most common clinical experience was prior to medical school, the majority reported “Other” at 47.7%. “Other” is categorized as a clinical experience other than a Scribe, Medical Technician/Physical Therapy (PT), Medical Assistant, Registered Nurse, Physician Assistant, Research Coordinator/ Research Specialist, or Surgical Technician. 31.6% reported prior experience as a Medical Technician/PT, and 7.9% reported prior experience of research coordinator/ research specialist. In regards to gap year(s), defined as taking time off between undergraduate/post-baccalaureate education and medical school, 13 out of 22 Current PGY’s indicated taking time off, reporting an average of 1.2 ± 1.3 gap years with a range of 0-5 years, and 18 out of 36 Prior PGY’s averaged 1.3 ± 1.9 gap years with a range of 0-7 years. There was no significant difference in gap years between Prior and Current PGY’s (t(54) = 2.00, p=.797).

Prior to residency, the average number of publications for Prior PGY’s was 1 ± 1 (range= 0-5), with a majority of 75% (n=23) having zero publications. Current PGY’s had an average of 4 ± 10 publications (range=0-45) with an outlier of 45 publications. The majority of this group had 0 publications (30%, n=7), 26% (n=6) had 1 publication, and 22% (n=5) had 2 publications. The results of the t-test indicated no significant difference between Prior and Current PGY’s number of publications (t(55) = 2.30, p = .0879).

Data regarding whether the participant elected to take USMLE Step 1 or 2 were evaluated. Out of 36 total responses in the Prior PGY group, the majority 69% (n=25) did not take Step 1. Out of the 12 Prior PGY’s who did take the USMLE Step 1, 50% (n=6) elected to take Step 2. When asked why they chose to take the USMLE, 25% (n=3) reported it was residency motivated, and 75% (n=9) reported they chose to take the exam out of personal interest/ satisfaction. Out of 22 total responses, the majority 73% (n= 16) of Current PGY’s elected to take Step 1, whereas 27% (n=6) did not. Of those who did take Step 1, 38% (n=6) elected to take USMLE Step 2. When asked why they chose to take the USMLE exam, 68% (n=11) reported being residency motivated, while 31% (n=5) reported personal interest/ satisfaction.

Orthopaedic auditions increased by an average of 1.5 auditions between Prior and Current PGY’s. Prior PGY’s had an average of 3.5 ± 1.7 auditions (range=0-7). Current PGY’s had an average of 5.0 ± 1 auditions (range= 4-7) (Figure 3). 77.8% (n=28) of Prior PGY’s rotated at their matched program, while 95.5% (n=21) of Current PGY’s rotated at their matched program. 

When applying to orthopaedic programs, Prior PGY’s submitted on average 11 ± 9 applications (range=1-30), whereas Current PGY’s submitted on average 29 ± 23 applications (range= 10-120) (Figure 4). The average number of residencies at which a Prior vs. Current PGY’s interviewed increased by 2, with Prior PGY’s averaging 3 ± 2.5 interviews (range=1-11), and Current PGY’s averaging 5 ± 2.1 interviews (range= 2-10) (Figure 5). When comparing the Pearson correlation coefficient between the groups, there was a significant positive correlation between number of applications vs. number of interviews for both Prior PGY’s (r=.428, p=.000003) and Current PGY’s (r= .349, p=.0002).

Discussion
This survey considered trends in some of the most prominent aspects of matching into an osteopathic orthopaedic residency. As a highly sought-after residency, orthopaedics continues to demonstrate competitive match interest indicated in this national orthopaedic membership. Additionally, osteopathic orthopaedic residency programs are known for selecting their residents based on the holistic picture of the candidate. Experiences prior to medical school between both groups, Prior vs. Current PGY’s, showed an overall trend towards Medical Technician/ PT, while the majority indicated “Other” category. This suggests growing opportunities of healthcare positions available to candidates, subsequently adding diversifying characteristics complimentary to the Profile 2.0, along with progressive enhancement of the varied experiences trending towards the holistic aspect of osteopathic physicians. 

Gap years may also play a part in an outstanding holistic residency application. From our analysis, the overall amount of gap years remained minimally changed between the Prior PGY and Current PGY groups, with both groups taking on average 1-2 years off between undergraduate education and medical school. These data are congruent with survey data conducted by the Association of American Medical Colleges (AAMC) in  2019. Out of 15,151 matriculating students (i.e. accepted and starting medical school), the majority, 43.9%, responded they took 1-2 gap years, and overall 65.2% reported taking at least 1 gap year (2). 

One of the most profound changes in our trends data is the number of publications each group had prior to residency. An overwhelming majority of Prior PGY’s had no prior publications, whereas the majority of Current PGY’s had at least one publication. While our study is self-reported data and not able to verify the validity of these publications, there is a clear trend toward more publications in Current PGY’s. Interestingly, the literature reports no longer any difference in allopathic senior orthopaedic application academic attributes of matched and unmatched orthopaedic surgery residency applicants regarding research products (abstracts, presentations, posters, and publications) admitting it has become less profound over time (3,4). Similarly, a separate report evaluating predictors of successful residency match in general surgery demonstrated research productivity with ≥4 abstracts, posters, or publications and ≥1 peer-reviewed publications to be just one of a combination of factors to be significant for successful match into general surgery (5). While suggestion has been made to medical schools to encourage students to prepare a holistic application for successful match into allopathic surgical residencies, our study confirms such practice continues to not only exist but thrive with historic track record of over 80 years embracing the true holistic approach of the osteopathic philosophy recognizing the multi-faceted orthopaedic candidates who successfully match into orthopaedic field and ultimately become AOAO members. 

Although the USMLE is not required for graduation from an osteopathic medical school, our study found that both Current and Prior PGY’s chose to take USMLE Steps 1 and 2. As of 2022, the USMLE changed from a scored result to Pass/Fail, so the data collected in this survey reflects data prior to this change. The majority of Prior PGY’s did not choose to take USMLE Step 1; however, the majority of Current PGY’s elected to take USMLE Step 1. Both groups reported lower numbers of USMLE Step 2 takers. The motivation differed between the two, from the majority of Prior PGY’s revealing choice due to “personal interest/ satisfaction” whereas in the Current PGY group it was “residency motivated”. This demonstrates no clear definitive reason either self-driven or training encouragement, thereby calling to question utility for an osteopathic orthopaedic application and certainly proves not necessary in successful match into orthopaedic residency. Notable of consideration a report among allopathic senior orthopaedic applicants who match and unmatched found increasing difficulty in prediction ability of a successful match based on USMLE Step scores among other academic attributes, further supporting as demonstrated in our study the unnecessary election for osteopathic applications with no advantage in orthopaedic field pursuit and successful match (3). It does appear, be it osteopathic or allopathic, that future studies should evaluate more subjective, holistic metrics for better understanding of optimal candidate quality and selection within the orthopaedic workforce.

The number of orthopaedic audition rotations increased between the two groups, with Current PGY’s completing more auditions than Prior PGY’s. Interestingly, the percent of participants who rotated at their current residency program increased between the two groups, with almost all of the Current PGY’s matching into a program at which a rotation was completed. Although Current PGY’s submitted more applications and interviewed at more programs than Prior PGY’s, our study demonstrates more applications did not correlate with a higher number of interviews. Despite a slightly higher correlation between number of applications and number of interviews in the Prior PGY’s group, it remains unclear the effect on ultimate match success. The Prior PGY’s group also spans more generations than the Current PGY’s group, lending itself to increased confounding factors in match outcome; including being the first class of residents within the growing osteopathic graduate medical education training system and different application processes, to name a few.

Our survey study does recognize limitations. Our analysis captured self-reported data from participants within membership of active AOAO orthopaedic surgeons and current PGY4-5’s. Overall, the sample of these populations was limited based on feedback. Additionally, since the survey was anonymous, there was no examination of the validity of the responses. Future consideration should include investigation of a larger sample , as well as comparison of the characteristics of PGY’s after the transition to a single GME accreditation system and after boards change to a Pass/Fail rather than numeric score, being imperative to analyzing the future of what might aid an osteopathic student Profile 3.0 to match into an orthopaedic residency. Despite the limitations of the study, this novel dataset is one of the only available at capturing most prominent osteopathic orthopedic resident characteristics over the past 40 years.

Conclusion
This study highlights the characteristics of successfully matched candidates over time both among current and prior osteopathic orthopaedic surgical residents. Overall, it captures an increasing trend of complexity to the Profile 2.0 applicant. Current residents show a slight increase in publications, an increase in number of auditions, and an increase in match success with an audition and interview at their ultimate residency program. Taking into account these conclusions, this study uniquely offers valuable understanding into the evolving AOAO membership including consistency in embracing an increasingly holistic individual within the future osteopathic orthopaedic workforce.

Acknowledgements
The authors would like to thank Joye Stewart, Jim Mason, DO, FAOAO, FAOA, and the staff at the AOAO who greatly aided us in our survey dissemination efforts. 

Figure 1 | Figure 2 | Figure 3 | Figure 4 | Figure 5

Required Disclosures and Declaration

Copyright Information: No Copyright Information Added
IRB Approval Information: Not applicable
Disclosure Information: No known conflicts of interest

References

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