Investigating trends in orthopedic surgery match for osteopathic and allopathic graduates post-single accreditation transition

To the Editor,

We appreciate Wood and Krumrey’s insightful publication, “Examining differences in trends in the orthopedic surgery match for osteopathic and allopathic medical graduates after the transition to single accreditation” [1]. Their work has acknowledged the disparities in orthopedic surgery match rates between osteopathic (DO) and allopathic (MD) applicants following the single accreditation merger between the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Association (ACGME) in 2020.

This study meticulously analyzed the National Residency Match Program (NRMP) data reports from 2018, 2020, and 2022 to demonstrate a consistent pattern of higher match rates for MD applicants compared to their DO counterparts. Although there was a consistent increase in orthopedic surgery applicants from both DO and MD schools, a higher trend in match rates was seen in MD applicants. Wood and Krumrey attributed this disparity to the fact that MD applicants demonstrated greater research output, including publications and research experiences, contributing to their competitive edge in securing orthopedic surgery residencies. They enumerated the ongoing challenges DO students face in accessing research opportunities, underscoring the need to address these disparities and implement systemic changes in medical education for a more equitable environment for aspiring orthopedic surgeons, regardless of their medical background. Wood and Krumrey concluded that these efforts would enhance opportunities and strengthen the competitiveness of osteopathic medical students aspiring to pursue orthopedic surgery. While we believe this to be true, we would like to expound on some potential challenges osteopathic medical students applying to orthopedic surgery face and offer possible solutions to aid osteopathic medical students in overcoming these barriers and optimizing successful matches into orthopedic surgery.

As osteopathic medical students interested in orthopedic surgery, we face many challenges addressed by this publication [1]. Orthopedic surgery is becoming increasingly competitive for both MD and DO applicants [2]. The single accreditation merger allows candidates from allopathic and osteopathic medical schools to be equally allowed to become orthopedic surgery residents by applying for the same programs [3]. However, DO applicants are disadvantaged compared to their MD colleagues due to the benefit of home orthopedic surgery programs for MD students [1]. This benefit allows MD students to receive training and early access to orthopedic surgery, research experiences, publications, increased preparedness in audition rotations, and, importantly, mentorship opportunities [1]. In addition, MD applicants had a statistically significantly higher number of abstracts, publications, and research experiences than DO applicants, further demonstrating the enhanced competitiveness of allopathic students when applying for orthopedic surgery residency [1]. The heightened competitiveness of MD applicants requires DO students to exert more effort to access these experiences, which may need to be more readily available at their home programs [3]. DO students typically have a heavier course load, numerous curricular and extracurricular commitments, and service activities related to the school’s mission, which can interfere with their time commitment to pursuing research opportunities [4], 5]. For example, DO students must complete at least 200 additional hours required in osteopathic manipulative techniques (OMT) compared to MD students who do not have this requirement; this takes time away from potential research and orthopedic shadowing opportunities that MD candidates may have due to the extra time [6]. Research has shown that DO and MD applicants have no statistical difference in board examination scores [1], 7]. It is crucial to emphasize that although there was a notable variance in research output, there were no statistically significant differences in the United States Medical Licensing Exam (USMLE) Step 1 or USMLE Step 2 Clinical Knowledge (CK) scores between DO and MD applicants [1]. When examining orthopedic in-training examinations (OITE) scores among DO and MD orthopedic surgery residents, the post-graduate year (PGY) 2, PGY 3, and PGY 4 residents demonstrated equivalent levels of orthopedic knowledge among residents from MD and DO medical institutions with similar scores seen on the OITE [7].

DO applicants must take the required Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 1 and COMLEX Level 2 Cognitive Evaluation (CE) to meet the board examination requirements. However, to become more competitive and for an apples-to-apples comparison, most DO applicants have been taking the USMLE Step 1 and USMLE Step 2 CK, although optional, at an increasingly high rate [5], 8]. In recent years, the USMLE Step 1 has been modified to compute a pass or fail report instead of a score, which may have lessened the ability of program directors from DO and MD orthopedic residencies to utilize objective measures to screen applicants [9]. DO applicants have also taken the USMLE Step 2 CK to assess their academic medical performance against other orthopedic residency candidates. The 2022 NRMP surveyed program directors from all orthopedic surgery residencies and found that biases remain in orthopedic residencies for DO applicants. Specifically, only 62.2 % of the program directions surveyed at the time were currently training an osteopathic physician [10]. This study showed that program directors seldom interviewed osteopathic candidates despite no significant differences in USMLE Step 1 and USMLE Step 2 CK scores [10]. Ultimately, the critical distinction between DO and MD medical students often lies in the availability of opportunities and resources.

Historically, DO graduates utilized the AOA to acquire residency positions. However, in 2020, the AOA and ACGME merger was instituted to open residency spots to both DO and MD graduates, which traditionally were restricted to DO graduates only [1]. One significant finding from Wood and Krumrey’s study that requires further discussion zeroes on the enrollment of MD candidates into previously known AOA residency positions. The ACGME has allowed former AOA orthopedic surgery residencies to apply for osteopathic recognition. During the merger, 36 formerly AOA-accredited orthopedic surgery programs transitioned to ACGME accreditation, but as of the 2023–2024 academic year, according to ACGME public reports, there are only five orthopedic residency programs with osteopathic recognition [11]. With fewer programs embracing osteopathic recognition, DO students face increased competition for limited spots, potentially impacting their ability to secure training in their desired specialty.

Furthermore, the disparity in available spots between DO and MD applicants and increased competitiveness highlight ongoing challenges in achieving equity and an equal playing ground within the orthopedic surgery match process. Despite the increased competitiveness of both DO and MD candidates, the match rate has plummeted for both MD candidates and DO candidates, as evidenced throughout the literature [3]. To accommodate DO students, orthopedic surgery residencies traditionally taking only MD students will also need to enroll DO candidates. Unfortunately, this transition with the ACGME merger, coupled with the lingering stigma that some formerly known ACGME programs have, has decreased available spots for osteopathic medical students interested in orthopedic surgery [12]. As the number of formerly known AOA programs accepting MD students has increased, we suggest that the program directors of ACGME programs eliminate the bias and stigma associated with DO candidates and matriculate qualified DO candidates into their programs.

We propose potential suggestions that DO candidates can implement to overcome barriers and optimize successful matches into orthopedic surgery as osteopathic medical students. First, students should maximize their chances by taking the USMLE Step 1 and USMLE Step 2 CK board examinations. Many formerly AOA-accredited programs have lost their osteopathic recognition status, leading to MD program directors in ACGME programs who may need help understanding COMLEX 1 and COMLEX 2 CS data [13]. Consequently, most program directors from non-AOA-accredited programs recommend or require DO students interested in competitive specialties like orthopedic surgery to take USMLE Step 1 and 2 CK [13]. Second, DO students must enhance their chances by completing away/audition rotations and sub-internships. These experiences are crucial and significantly increase the likelihood of enrolling in orthopedic surgery programs [13], 14]. Despite potential financial burdens due to higher application fees imposed by residency programs, DO students should prioritize rotating, especially at former AOA-accredited programs [13]. Thirdly, DO candidates should seek mentorship and pursue orthopedic surgery opportunities. In the digital age, candidates should utilize social media platforms like Twitter/X (and specifically utilize hashtags such as #OrthoTwitter and #MedTwitter) and seek access to orthopedics through program directors, chairs, associate program directors, program coordinators, professors, faculty, and residents across various orthopedic programs. DO students can benefit from organizations that specifically assist medical students, such as the Student American Osteopathic Academy of Orthopedics, the American Academy of Orthopedic Surgeons, Medical Student Orthopedic Society, Ruth Jackson Orthopedic Society, Student National Medical Association Orthopedic Surgery Interest Group, Pride Ortho, J. Robert Gladden Orthopedic Society, Nth Dimensions, and The Perry Initiative, in addition to local orthopedic surgery interest groups. Fourthly, DO institutions must emphasize the importance of research when guiding orthopedic residency applications. In their assessment of the competitiveness of orthopedic surgery applicants, Martinez et al. revealed that research output (i.e., the average number of publications) among DO and MD orthopedic surgery applicants has quadrupled from 3 to 14 between 2003 and 2022 [15]. During the 2003 to 2022 study period, the average number of reported research publications increased for both DO applicants (4.0–7.0) and MD applicants (11.5–16.5). Thus, DO applicants should pursue scholarly activity and ensure they produce quality research, submit and present their abstracts at conferences, and finalize their findings through peer-reviewed publications.

This study highlights the disparities in orthopedic surgery match rates for DO and MD candidates. We hope DO candidates see the difficulty of matching into orthopedic surgery and the evidence provided through the match rate data [16]. However, despite the decrease in match rates, applying these recommendations can be a stepping stone to apply to orthopedic surgery residency confidently. We believe that this letter will serve as a catalyst for future research regarding the disparities of match rates between DO and MD candidates and encourage all ACGME programs, regardless of their former AOA or osteopathic recognition status, to take candidates who best fit their program requirements, irrespective of their allopathic or osteopathic background.