Training Tomorrow's Hand Surgeons: Clinical, Leadership, and Structural Trends in Fellowship Education

Hand surgery fellowships include trainees from orthopedic, plastic, and general surgery. These pathways present an opportunity to examine variations in graduate medical education structures, such as program size, sponsoring department, and leadership composition. Limited research exists on the characteristics of these programs. The purpose of this study is to assess the structural and leadership characteristics of the Accreditation Council of Graduate Medical Education-accredited hand surgery fellowships in the United States. We hypothesized that characteristics (ie, faculty-to-fellow ratios and case volume) vary by specialty sponsorship. Leadership, although shaped by merit-based criteria, faces challenges in achieving broader demographic diversity.

A cross-sectional analysis of 95 US hand surgery fellowship programs was conducted in 2025. Program characteristics were compared by region and specialty sponsorship.

Most programs were orthopedic-sponsored (n = 74, 77.9%), followed by plastic surgery (n = 19, 20.0%) and general surgery (n = 2, 2.11%). Programs averaged 2.22 fellows (SD = 1.35), with a faculty-to-fellow ratio of 3.98 (SD = 2.01) and an annual case volume of 846 per fellow (SD = 332). Orthopedic-sponsored programs had more fellows on average, a lower faculty-to-fellow ratio, and were less open to general surgery applicants compared to plastic surgery-sponsored programs. No notable regional differences were found in these characteristics. Program directors were predominantly men (n = 81, 85.3%) and orthopedic-trained (n = 70, 73.7%).

Hand surgery fellowships show consistent structural features, with notable differences between orthopedic- and plastic surgery-sponsored programs in enrollment, faculty-to-fellow ratios, and openness to general surgery applicants. Women leadership underrepresentation warrants further evaluation.

Cross-sectional descriptive study, level IV.