1 Introduction

Orthopaedic surgery is an ever-evolving field that heavily relies on continued research findings. Orthopaedic residents are critical contributors to academic productivity and the resulting clinical advancements.¹ Research plays a role in every level of training in orthopaedics and is particularly important for those pursuing careers in academia. Recent studies have found that research programs within the field of orthopaedics need increased support.²

Several factors contribute to academic productivity, including institutional and individual factors.³ Residency reputation is associated with research productivity. Scholarly productivity is known to impact the reputation of orthopaedic surgery residency programs; however, the role that orthopaedic residents play in academic productivity is unclear. Highly reputable residency programs may or may not be associated with increased resident research output in orthopaedics.

Females are underrepresented in orthopaedic surgery, making up only 5.9% of active orthopaedic physicians.⁴ While women are known to be underrepresented in this field, female presence is actively growing.⁵ Similarly, female representation has been rising at national academic orthopaedic meetings.⁶ Therefore, gender is an essential factor when analyzing academic productivity.

Numerous studies have been conducted that discuss factors associated with increased academic productivity in general surgery residents. These studies have found that research productivity is associated with higher ranking residency programs, the number of publications before residency, and the introduction of formal research programs, but not with geographic region.^7–9 Similar studies conducted in plastic surgery found that number of years of training, program reputation, and graduation from a medical school with high research ranking were associated with increased research productivity of residents.¹⁰ However, no such study has been conducted in orthopaedics. The primary goal of this study is to determine if factors, including program reputation, resident gender, and program region, are associated with the research productivity of orthopaedic surgery residents.

2 Material and Methods

We gathered a list of accredited orthopaedic surgery residency programs using the list of programs available on the Accreditation Council for Graduate Medical Education (ACGME) website. We organized these programs by program rank using Doximity Residency Navigator research ranking, a widely used ranking system for residency program.¹¹ Other program demographic variables collected include geographic region and affiliation with a medical school. Geographic areas were stratified based on state into four broad regions: Northeast, South, Midwest, and West.

Orthopaedic surgery residents from 2021 to 2022 were identified using program websites. We identified the resident gender as male or female using photographs and pronouns, if available on program websites. When photographs were unavailable, we searched the resident name for an associated Doximity profile to determine gender. The resident's associated residency program, training year (PGY1, PGY2, etc.), and medical school were collected. We noted residents who came from the top 20 research medical schools and those who were at residencies with affiliated top 20 research medical schools. We determined if medical schools were top 20, specifically in research, by using the well-known ranking published by the U.S. News & World Report “Best Medical Schools”: Research.¹²

Identified residents were searched by first and last name on Scopus and PubMed. We gathered all publications available on these websites that were published starting from July 1 of the resident PGY1 year through December 31, 2021. All identified publications were classified by article type. The articles were noted as ‘original’ if they included original research; all other articles were classified as ‘non-original’. These other article types included systematic review, meta-analyses, case reports, case series, perspective articles, editorials, letters to the editor, and book chapters. We also noted other aspects of the publication, including authorship position, particularly first, second, or last, and affiliated journal. An article was designated as published in a top orthopaedic surgery journal if it was published in an orthopaedic surgery journal with a top 15 impact factor at the time of this study. Residents were defined as having “high research output” if their output was greater than or equal to the 75th percentile compared to other residents in their training year.

We used chi-square analysis to compare resident gender to training year, program geography, resident medical school ranking, ranking of the medical school affiliated with the residency program, and proportion of residents with “high research output” as previously defined. Comparisons between gender and total article output in general and by training year, percentage of time as first, second, or last author, and proportion of time publishing in a top orthopaedic surgery journal were completed using Mann-Whitney U tests. Statistical significance was determined by a p-level of less than 0.05.

3 Results

Two hundred and one ACGME-accredited orthopaedic surgery residency programs were identified, and sixteen of the top twenty-five Doximity-ranked programs were analyzed. Within these programs, 560 residents were identified. Of the 560 residents, 423 (75.5%) were male and 137 (24.5%) were female. There were no significant differences found in distribution between male and female residents for year of training (p = 0.119), residency program geographic distribution (p = 0.969), residents from a top 20 medical school (p = 0.803), or residents attending a program affiliated with a top 20 medical school (p = 0.573) (Table 1). There were no significant differences between the proportion of males and females having high research output (p = 0.578).

The median number of overall publications was 3 per resident. When stratified by class, the median number of publications per resident was 1, 2, 3, 5, and 7, respectively, for the PGY1 through PGY5 classes (Table 2). Male and female residents both had a median of 3 total articles, but the distribution between them produced a statistically significant difference (p = 0.004). When stratified by post-graduate year class, there was no statistically significant difference between the number of total publications between male and female residents. There were no differences between male and female residents in the first, second, or last authorship position (p = 0.804) (Table 2). There was a statistically significant difference between male and female residents in the percentage of times published in a top orthopaedic surgery journal (p = 0.027). The mean percentage of publications in a top journal was 13.1% overall (22%), 13.7% (21.9%) for male residents and 11.3% (23.3%) for female residents.

There was no statistically significant difference in research productivity by region, except for the Northeast, where residents produced significantly more publications (p < 0.001) (Table 3). Furthermore, residents from medical schools ranked as top 20 research institutions had significantly higher productivity during residency (p = 0.022), while this did not hold for residents at residency programs affiliated with the top 20 medical schools (p = 0.360).

4 Discussion

Factors associated with increased research productivity during residency training include male gender, medical school ranking, and residency program in the Northeast region. It is interesting to note that overall, male orthopaedic surgery residents had higher research output than their female counterparts, which did not hold after stratification by year of training. Similarly, male residents had a higher percentage of publications tat were published in top orthopaedic journals, but they did not have more publications in first, second, or last authorship positions. It is important to note that there were no significant differences in gender distribution by training year, geographic region, or ranking. These factors are noteworthy given that specific residency and training institutions may have increased funding and more productive, resourceful laboratories than institutions.

While gender parity is coming to fruition in other fields of medicine, orthopaedics has notably lagged in this regard. The proportion of female faculty within orthopaedic surgery is increasing, but it is not near the advances other specialties have made.¹³ Women continue to be underrepresented in academic medicine, particularly at the highest levels.¹⁴ Other surgical specialties are coming closer to research gender parity, specifically regarding research productivity.¹⁵ Despite the increase in female representation within orthopaedics, women in this field continue to face barriers that hinder their scholarly productivity. This finding indicates that, although improving, gender differences still exist within orthopaedic surgery and within academic productivity overall. These findings are relevant for orthopaedic surgery applicants who strongly value research in their training and career.

A study by Bajaj et al. found that attending a high-ranking research medical school was associated with increased research output for cardiothoracic surgery attendings.¹⁶ Plastic surgery residents have also been found to have higher research productivity when attending medical schools associated with top research ranking medical schools.¹⁰ Interestingly, our study came to the same conclusion with orthopaedic surgery residents. This finding is important as it exemplifies how the foundation for academic productivity begins in medical school and develops into lifelong skills. The research skills provided by top-ranked and research-productive medical schools will persist for physicians as they continue to participate in research throughout their careers.

Another interesting finding is that the Northeast location of the residency program was associated with increased research productivity. Historically, the Northeast and West regions were more likely to train women and minorities, while the opposite was true for the South.¹⁷ A previous study noted that orthopaedic sports medicine fellowship applicants from the Northeast region were more likely to have completed more publications than applicants from other regions.¹⁸ Another study showed that spine surgeons who are attending residency or who are currently practicing in the Northeast had higher publication rates.¹⁹ Our analysis demonstrates that all residents, no matter which fellowship they pursue, are more likely to have increased academic productivity if they attend residency within the Northeast. This finding is likely secondary to the disproportionately high number of research institutions and increased funding in the Northeast compared to orthopaedic residency programs in other regions.

There are strengths and limitations to this study. Gender was determined based on the resident name in combination with pronoun and gender presentation in resident photographs. Using this method, gender classification may not perfectly align with the resident gender identity, especially when pronouns were unavailable. Similarly, we classified gender as male and female and did not include nonbinary genders in our analysis. Our study did not analyze the correlation of program size and research productivity. Program size may be a confounding factor as programs with more residents who cover more hospitals may often receive more funding for research. Additionally, July 1 was used as a cutoff date to establish the beginning of the resident's training at the program. However, this cutoff likely resulted in the inclusion of research projects conducted before the start of residency and published afterward. We also may not have identified all residents with research years, as programs list PGY year as either the current year or the year just finished if in the middle of a research year. A further limitation of this study is that some residents had common names. As a result, we had to make judgment calls on whether certain publications were associated with the correct resident. Likewise, we may have missed some publications if female residents changed their surname at any point during training or practice. Lastly, we could not analyze residents from all orthopaedic residency programs due to the large sample size.

5 Conclusions

Research is a crucial component of residency training in orthopaedic surgery. This article adds to the limited information studied regarding factors associated with the academic productivity of orthopaedic residents.

CRediT authorship contribution statement

Alexis M. Driscoll: Formal analysis, Data curation, Resources, Writing – original draft. Christopher J. Hawryluk: Data curation, Writing – review & editing. Rebecca Klausner: Data curation, Writing – review & editing. Isabel H. Herzog: Data curation, Writing – review & editing. Claudia Siniakowicz: Conceptualization, Methodology, Writing – review & editing. Kathleen S. Beebe: Conceptualization, Validation, Writing – review & editing, Supervision.

Informed consent

Informed consent was not necessary to be obtained for this study.

Ethical statement

Institutional Review Board Approval is not necessary for this non-human subjects review of public data.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.