Foot and ankle fellowship-trained osteopathic orthopaedic surgeons: a review, analysis, and understanding of current trends

Osteopathic physician perspective on training

Osteopathic and allopathic degrees are recognized as equivalent by state licensing agencies and many healthcare institutions [12]. Few differences are encountered in osteopathic and allopathic curricula from a medical education perspective. Osteopathic and allopathic medical students are both exposed to the classic structure of two preclinical didactic years, followed by two clinical clerkship years. The basic science courses encountered in the preclinical years are consistent [12, 13]. State licensing examinations, the National Board of Osteopathic Medical Examiners (NBOME) Comprehensive Osteopathic Medical Licensing Examination (COMLEX) “level,” and National Board of Medical Examiners (NBME) “step” examinations, test similar content [14].

Osteopathic medical students engage in supplemental coursework that explores the philosophy behind the practice of osteopathic medicine. Osteopathic Principles and Practice (OPP) incorporates the Principles of Osteopathy into traditional medical coursework. These principles are rooted in the notion that the primary role of the osteopathic physician is to facilitate the inherent ability of the patient’s body to heal itself [15]. Students are also required to participate in “lab”-based instruction in osteopathic manipulative therapy, requiring knowledge of anatomic structure and their functional interrelations [16]. This “hands-on” course requires students to have advanced knowledge of these anatomical relationships and the manipulation thereof. These additional skills and advanced anatomical knowledge may serve DOs well in subspecialty residencies and fellowships, especially orthopedic surgery.

Osteopathic physician and resident trends

Over the past decade, there has been an increasing number of osteopathic medical school graduates, and an increasing percentage have been entering surgical training programs and their subsequent fellowships [13]. According to the Federation of State Medical Boards, there were 58,329 osteopathic physicians licensed to practice medicine in the United States and the District of Columbia in 2010, comprising 6.9 % of all physicians [22]. The number of osteopathic physicians increased to 89,764 in 2018, representing 9.1 % of all practicing physicians [23]. Subsequently, the 2020–2021 Osteopathic Medical Profession Report noted that the number of osteopathic physicians increased to approximately 135,000, currently representing 11 % of all physicians [24].

Trends in foot and ankle fellowship participation

The American Foot and Ankle Society was founded in 1969 by seven colleagues who were concerned about the absence of courses centered around the foot at the American Academy of Orthopaedic Surgeons (AAOS) meetings. Jahss and colleagues [25] noted that foot and ankle pathology composed roughly 20 % of the orthopedic surgeon’s practice and the society’s goal was to further education, innovation, and research in foot and ankle.

Foot and ankle as a subspecialty within orthopedic surgery that has seen an increasing number of one-year fellowship training positions offered over the past decade. In 2010, 58 positions were offered through 34 participating programs. This number increased to 75 positions through 47 programs just Five years later in 2015 [2]. By 2021, 79 positions were offered through 49 programs (Table 1) [11, 26].

Currently, there are 1,103 active AOFAS members [27], equating to approximately 5 % of practicing orthopedic surgeons, with 110 of these members being DOs (Jessica Dornfeld, BA, Director of Marketing and Membership, AOFAS; e-mail communication, June 2022). DOs represent only 10 % of the AOFAS’s membership and 0.5 % of all practicing orthopedic surgeons [28]. However, osteopathic membership in the society has been steadily increasing in recent years. According to data obtained from correspondence with the AOFAS, the number of DO members has increased from 84 osteopathic-trained orthopedic physicians in 2016 to 110 in 2022 (Figure 1) (Jessica Dornfeld, BA, Director of Marketing and Membership, AOFAS; e-mail communication, June 2022).

Figure 1:

Osteopathic American Orthopaedic Foot and Ankle Society (AOFAS) members, total, 2016–2022.

Historically, there has been an increasing trend of DOs pursuing foot and ankle fellowships from 2012 to 2018 (Figure 2). DO representation increased from four fellows in 2012 to nine in 2018. The percentage of DO residents representing those who matched into foot and ankle fellowships increased from 6.7 % in 2016 to 14.8 % in 2018. However, despite this hopeful trend in DO participation in foot and ankle fellowships, the 2019 match year saw a drop to 7 DO foot and ankle fellows (12.5 %). Furthermore, there was a significant drop in the 2020 and 2021 match years, with only two osteopathic fellows for both years (or 3.4 % and 3.5 % of all foot and ankle fellowship candidates holding osteopathic degrees, respectively) (Jessica Dornfeld, BA, Director of Marketing and Membership, AOFAS; e-mail communication, June 2022) [11].

Figure 2:

Osteopathic foot and ankle fellows by match year, 2012–2022.

Although the 2020 and 2021 match years may have seen a drop in DO interest in foot and ankle fellowship, this was also seen across the US among MD candidates, as well (Figure 3). In 2019, there was a decline to 56 fellows, from 61 fellows the previous year (2018). Year 2020 had an increase in two fellows to 58, while 2021 declined again to 57 fellows across foot and ankle training programs [11]. By 2022, the number of DOs accepted into foot and ankle fellowship doubled to 4, with 54 positions filled in the match (Jessica Dornfeld, BA, Director of Marketing and Membership, AOFAS; e-mail communication, June 2022). Although the number of DOs in foot and ankle fellowship doubled to four from the previous year (2021), a consistent total number of residents matched (Jessica Dornfeld, BA, Director of Marketing and Membership, AOFAS; e-mail communication, June 2022) [11]. This could be related to an increasing number of graduating osteopathic residents matching into orthopedic surgery, an uptick in interest in foot and ankle for the graduating residents, or another factor.

Figure 3:

Graph demonstrating trends of total foot and ankle fellowship positions available, completed applications, the number of candidates who submitted rank lists, positions filled in match, post-match positions filled, and total number of positions filled, 2016–2021 [11].

The apparent decline in interest does not appear to follow a particular pattern or be centered around a definable event. One possible explanation for the more recent apparent decline in interest in foot and ankle could be that only seven out of 48 (14.6 %) of foot and ankle fellowship programs were accredited for the 2021 match year [29]. However, interest in subspecialty fellowships has been previously noted to wax and wane. These noted trends could be multifactorial from both realized and unrealized factors, including the perception for specialty saturation in the job market, natural fluctuation of graduating resident interest, degree of exposure to the subspecialty during residency, odds of matching into an applicant’s first choice, or the apparent societal need for the subspecialist [30].

The recent decline and stagnation in the number of graduating orthopedic and osteopathic orthopedic residents completing fellowships in foot and ankle surgery must be further investigated and ultimately addressed, as there is a projected national shortage of orthopedic foot and ankle surgeons.

This current study has several limitations. Multiple organizations are involved in the match process for orthopedic fellowships across all subspecialties, that includes both accredited and nonaccredited programs. Reliable and consistent data available for review are lacking, with the data available publicly inconsistently distinguishing between degree (Allopathic vs. Osteopathic) and graduates from the United States and foreign medical graduates. The AOFAS had limited internal data available for review from the years 2012 to 2021. Finally, this study was a retrospective review of the trends of foot and ankle fellows, therefore the motives and personal decision-making of the individual decisions for pursing a particular fellowship was unable to be elucidated.