Geographical distribution and match trends of osteopathic residents in otolaryngology residency programs: a cross-sectional analysis

Study design

This retrospective cross-sectional study analyzed the geographical distribution and representation of osteopathic otolaryngology residents in ACGME-accredited otolaryngology residency programs across the United States over a 5-year period from 2020 to 2024, following the SAS merger. The study aimed to assess changes in the geographical distribution of osteopathic otolaryngology residents, examine their placement in urban vs. rural programs, analyze hospital sizes where they train, and explore the correlation between the number of osteopathic medical school locations and osteopathic resident placements. Additionally, the study evaluated the medical school representation among osteopathic otolaryngology residents and analyzed the geographical mobility of these residents by examining whether they trained in the same state as their medical school or relocated to a different state for residency. Because the study collected only post-SAS data from 2020 through 2024, no premerger baseline comparison was made. Consequently, all reported changes in geographical distribution reflect year-to-year variation within this 5-year postmerger period.

Data collection

A complete dataset was created and included information on osteopathic otolaryngology residents’ postgraduate year (PGY), residency program, city, state, and medical school attended. The total number of osteopathic otolaryngology residents (n=109) was cross-checked against the National Resident Matching Program (NRMP) website (NRMP.org) [13]. Residency program details were cross-referenced with publicly available sources, including program websites, LinkedIn, Doximity, and X (formerly Twitter). Medical school data were grouped to evaluate the distribution of osteopathic residents from different osteopathic schools.

Inclusion and exclusion criteria

All osteopathic graduates who matched into ACGME-accredited otolaryngology programs during the study period were included. Residents who matched into military programs were excluded.

Measures and variables

Hospital bed counts were obtained from the American Hospital Directory and individual hospital websites, reflecting the most recent data available up to October 2024. Hospitals were categorized based on bed count into small hospitals (<100 beds), medium hospitals (100–399 beds), and large hospitals (≥400 beds). For programs affiliated with multiple hospitals, the average number of beds was calculated by averaging the beds of the associated hospitals.

Residency program locations were classified as urban or rural based on the Rural-Urban Commuting Area (RUCA) codes provided by the United States Department of Agriculture (USDA). A RUCA code of 1.0 indicates an urban area, whereas codes greater than 4.0 indicate rural areas.

The number of osteopathic medical school locations per state was obtained from the American Association of Colleges of Osteopathic Medicine as of 2024, which lists 42 osteopathic medical schools with 67 teaching locations across the United States. Geographical mobility was assessed by comparing the states where residents attended medical school with the states where they trained.

The primary outcomes included the geographical distribution and representation of osteopathic residents in otolaryngology residency programs. Secondary outcomes included the correlation between the number of osteopathic medical school locations in a state and the number of osteopathic otolaryngology residents in that state’s otolaryngology programs, as well as the analysis of hospital sizes and urban vs. rural settings. Additional variables included the number of osteopathic otolaryngology residents from each osteopathic medical school and the geographical mobility of residents based on the location of their medical school and residency program.

Statistical analysis

Descriptive statistics were calculated for the categorical variables, including frequencies and percentages. A Pearson correlation coefficient was computed to assess the relationship between the number of osteopathic medical school locations per state and the total number of osteopathic otolaryngology residents in otolaryngology programs in that state. A chi-square test for trend was performed to assess changes in the geographical distribution of osteopathic otolaryngology residents across different states over the 5-year period.

For medical school representation, the number of residents from each osteopathic medical school was tabulated, and the top contributing osteopathic medical schools were identified. Geographical mobility was assessed by comparing the state of the medical school with the state of the residency program for each resident. A two-sample t test was performed to compare the geographic distance (in miles) between residents who stayed in-state and those who relocated to a different state for residency.

All statistical analyses were performed utilizing RStudio (Version 2024.04.1+748) and Microsoft Excel. Statistical significance was defined as a p value of less than 0.05. This study was reviewed and verified by the Lincoln Memorial University Institutional Review Board (IRB) as Not Human Subjects Research, because it involved publicly available, nonidentifiable data.

Geographic location of residencies

A total of 109 osteopathic otolaryngology residents were identified from all ACGME-accredited otolaryngology residency programs that participate in the NRMP spanning 15 states [13]. Michigan, Pennsylvania, and Ohio exhibited the greatest representation, collectively accounting for approximately 74.3 % (n=81) of these osteopathic residents. In 2020, osteopathic graduates filled 16 of 64 positions (25.0 %) across these three states: Michigan had 7 of 20 total residents (35.0 %), Pennsylvania had 5 of 24 (20.8 %), and Ohio had 4 of 20 (20.0 %) [13]. By 2024, they represented 19 of 73 positions (26.0 %) in those states: Michigan at 9 of 21 (42.9 %), Pennsylvania at 6 of 30 (20.0 %), and Ohio at 4 of 22 (18.2 %) (Figure 1) [13]. All 109 osteopathic otolaryngology residents trained in programs classified as urban (RUCA code 1.0).

Figure 1:

This heatmap illustrates the distribution of osteopathic otolaryngology residents across residency program states from 2020 to 2024, highlighting geographical concentrations and trends over time.

Matching in historically AOA-accredited vs. historically allopathic-only programs

There are 42 osteopathic medical schools distributed across 67 teaching locations nationwide in 2024 (Figure 2). Of the 27 programs that accepted osteopathic residents, 14 were historically AOA-accredited programs that transitioned under SAS, and 13 were historically allopathic-only programs from 2020 to 2024 (Figure 3). Nineteen allopathic residents trained in historically AOA-accredited programs from 2020 to 2024, reflecting the evolving, integrative nature of these residencies post-SAS merger. A total of 31 osteopathic medical schools were represented among the 109 osteopathic otolaryngology residents.

Figure 2:

The top-left map shows the state-level distribution of osteopathic otolaryngology residents, while the top-right map highlights the geographical origins of osteopathic medical students who matriculated into otolaryngology programs. The bottom map provides the location of osteopathic medical schools across the United States as of 2024.

Figure 3:

This comparison highlights the number of osteopathic residents who matched into historically AOA-accredited otolaryngology programs vs. historically allopathic-only programs from 2020 to 2024, illustrating trends following the SAS merger. No state has residents from both historically AOA-accredited and historically allopathic-only resident programs in otolaryngology.

Medical school representation

Five osteopathic medical schools accounted for approximately 39.4 % (n=43) of all osteopathic otolaryngology residents, with Michigan State University College of Osteopathic Medicine alone contributing 10.1 % (n=11). Other top contributing institutions include Philadelphia College of Osteopathic Medicine (Pennsylvania), McLaren Health Care (Michigan), Freeman Health System (Missouri), and Oklahoma State University Center for Health Sciences (Oklahoma), emphasizing the influence of home or affiliated residency programs on match outcomes.

Osteopathic otolaryngology residents have matched into historically allopathic-dominated programs at institutions such as Duke University (Durham, North Carolina), Baylor Scott & White Health (Temple, Texas), George Washington University (Washington, D.C.), and the University of Vermont Medical Center (Burlington, Vermont). Although there was a temporary bump in the absolute number of osteopathic matches in 2022 and 2023, the figure decreased again in 2024 (Figure 4). Accounting for the overall increase in residency positions post-SAS, the proportion of osteopathic residents in historically allopathic programs has remained relatively stable. Consequently, these data do not suggest a consistent upward trend in osteopathic acceptance at allopathic programs.

Figure 4:

The distribution of osteopathic otolaryngology residents is shown based on the size of the hospitals where they matched for residency, categorized as small, medium, or large, from 2020 to 2024.

Trend analysis

The chi-square test for trend showed no statistically significant change in the geographical distribution of osteopathic otolaryngology residents over the 5 years (p=0.54). Pearson correlation revealed a moderate positive relationship between the number of medical school locations and resident counts by state (r=0.38, p=0.014). A regression analysis showed that for each additional osteopathic medical school location in a state, there was an associated increase of approximately 2.5 osteopathic otolaryngology residents in otolaryngology programs (p=0.014).

Hospital size distribution

Otolaryngology residency program–affiliated hospital sizes for osteopathic physicians were verified utilizing the most recent data available on each hospital’s website. The distribution of osteopathic otolaryngology residents by hospital size is presented below. The distribution reveals that the majority, 88 residents (80.7 %), are trained in large hospitals with 400 or more beds (Figure 5). Medium hospitals, with a bed count range of 100–399 beds, account for 21 residents, representing 19.3 % of the total. Notably, no residents are trained in small hospitals with fewer than 100 beds, as reflected by a 0 % representation in this category. An analysis of variance (ANOVA) test indicated no significant change in the distribution of residents among hospital sizes over the years (p=0.37), suggesting that the preference for larger hospitals remained consistent.

Figure 5:

The trends in otolaryngology residency matches among osteopathic medical students are displayed, with results divided between historically AOA-accredited and historically allopathic-only programs from 2020 to 2024, showing shifts in program selection patterns over time.

Geographic mobility

An analysis of geographical mobility showed that 62 out of 109 residents (56.9 %) trained in the same state where they attended medical school, whereas 47 residents (43.1 %) relocated to a different state for residency. To assess whether there was a meaningful difference in geographic movement between those who stayed in-state and those who trained out-of-state, a two-sample t test was performed comparing the distance between each resident’s medical school and residency location. The mean distance for residents who stayed in-state was 121.1 miles, whereas those who trained in a different state had a significantly higher mean distance of 697.3 miles. The t test yielded a statistically significant result (t = −3.34, p=0.014). These findings suggest that while over half of residents remained in-state, those who relocated moved significantly greater geographic distances.

Challenges and structural considerations

While the transition to an SAS in 2020 allowed for new avenues of opportunity for osteopathic graduates seeking residency placement, disparities in program distribution, historical biases, and structural inequities continue to shape osteopathic access to competitive specialties [17], 18].

Traditional osteopathic medical education has emphasized holistic care and osteopathic manipulative treatment (OMT) [19]. However, these are historically not core components of otolaryngology education, and emphasizing them may not align with the primary focus of otolaryngology residencies. Residency programs that are committed to continuing the teaching and assessment of Osteopathic Principles and Practice (OPP) throughout training are designated as having Osteopathic Recognition (OR) by the ACGME’s Osteopathic Recognition Committee. Maier et al. [20] demonstrate that although OR programs lead to a higher recruitment of osteopathic students, OR programs are underrepresented within surgical programs, including otolaryngology. Currently, there are only four OR otolaryngology residency programs in the United States that are recognized by the ACGME [21]. One challenge to broader acceptance of OR programs is the lack of sufficient evidence demonstrating the clinical efficacy of OMT in areas relevant to surgical specialties, including in the treatments of otolaryngologic conditions. Although some studies have suggested potential benefits of OMT in specific contexts [22], 23], the relative lack of substantial randomized controlled trials (RCTs) remains a main criticism [24]. The burden of maintaining OR standards may not be appealing to many programs, because it requires additional resources and effort without clear evidence of its effectiveness at increasing osteopathic representation, enhancing specialty-specific academic contributions, and clinical significance [25]. However, OR programs offer a unique opportunity to provide osteopathic residents with a more holistic approach to patient care, complementing their surgical training with additional skills that align with the osteopathic philosophy. Furthermore, OR programs meet the same rigorous ACGME accreditation standards as other residency programs, ensuring high-quality training seamlessly integrated into allopathic surgical practices. This dual focus allows osteopathic residents to maintain their distinctive identity while also preparing them for the demands of competitive surgical specialties, including otolaryngology. While the primary focus of otolaryngology remains surgical and technical, the inclusion of OMT in OR programs can serve as a supplementary tool, broadening the scope of training and enhancing adaptability in clinical practice.

Limitations

The analysis was based on the data of 109 osteopathic otolaryngology residents and does not include osteopathic otolaryngology residents in military otolaryngology programs. The classification of hospital sizes and urban settings was based on the most recent data available but may be subject to change due to hospital expansions or reclassifications. Additionally, the study did not account for other factors influencing residency placement, such as applicant competitiveness, program preferences, or regional demand for otolaryngologists.

Future directions

This study’s focus on osteopathic otolaryngology residents does not provide a comprehensive comparison with allopathic residents. However, preliminary data from the NRMP suggest that both allopathic and osteopathic trainees predominantly match into urban, high-volume academic centers. Future research that evaluates allopathic and osteopathic cohorts in parallel at the program level would clarify whether these post-SAS trends apply universally or primarily affect osteopathic graduates.

Additionally, the adoption of a pass/fail model for Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) Level 1, mirroring the shift in United States Medical Licensing Examination (USMLE) Step 1, may further standardize how residency programs evaluate applicants. This change could potentially remove some perceived barriers for osteopathic students. Investigating whether this transition influences osteopathic match rates in highly competitive specialties remains an important avenue for ongoing research.

Future research should also include data on allopathic residents to provide a comprehensive analysis of residency trends and to allow for meaningful comparisons between osteopathic and allopathic graduates. Examining the factors that guide osteopathic otolaryngology residents’ choices, such as mentorship opportunities, program reputation, and geographic preferences, could illuminate strategies for improving residency placement [19]. Finally, assessing the impact of medical school outreach programs and partnerships may help explain how specific institutions effectively funnel graduates into otolaryngology residencies.