Program Size and City Characteristics May Be Associated With Gender Diversity in Orthopaedic Surgery Residency...

Orthopaedic surgery remains one of the least gender-diverse specialties in medicine. Prior studies have identified factors that influence a woman applicant's rank list, such as surgical experience, women faculty, and resident satisfaction; however, little is known about how the geographic location of a program is associated with the gender composition of residency classes.

(1) Is the geographic location of an orthopaedic surgery residency program associated with the proportion of women in its residency class? (2) After adjusting for potential confounders like program size and type, what program- and city-level factors are associated with a higher percentage of women in orthopaedic residency programs?

Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic residency programs with updated resident lists for the 2025 to 2026 academic year were included; we included 204 such programs from a total of 212. Resident gender was determined using photographs, biographies, and preferred pronouns when available. The proportions of women residents were compared across US geographic divisions as defined by the Electronic Residency Application Service (ERAS®). Secondary analyses explored whether program characteristics (program type, women faculty proportion, gender of chair and program director) and city-level factors (population density, median household income, crime rate) were associated with gender distribution. An independent-samples Kruskal-Wallis test was used to compare the percentage of women between geographic divisions, and multivariable linear regression was used to adjust for covariates and identify factors associated with a higher proportion of women in a program. For interpretation of correlation strength, we classified coefficients as slight (|r| = 0.10 to 0.29), modest (|r| = 0.30 to 0.49), and substantial (|r| ≥ 0.50), which is consistent with commonly used conventions. Statistical significance was set at p < 0.05.

Of the 204 programs included, the percentages of women residents were not different when comparing the nine locations as defined by ERAS. After controlling for potential confounding variables such as number of total residents, program type, and city education level (% of the population with at least a bachelor's degree), we found that larger programs were modestly associated with higher percentages of women in the programs (regression coefficient [β] 0.28 [95% confidence interval (CI) 0.07 to 0.49]; p = 0.01). Additionally, compared with university programs, community programs had a mean of 5% fewer women residents (95% CI -8% to -2%; p < 0.001).

Our findings highlight differences in gender representation across orthopaedic surgery residency program types and sizes but do not identify causal factors or barriers. Programs seeking to increase gender diversity may wish to consider evaluating their size, recruitment strategies, and applicant outreach in light of these associations, while candidates interested in more gender-diverse environments might consider these program characteristics when applying.

Addressing gaps in gender representation across orthopaedic surgery residency programs may not only improve gender balance in training but could also have downstream benefits for patient care and surgical team effectiveness. Future studies can build on this work by conducting a survey study to directly assess how program size and academic affiliation influence applicant decisions in orthopaedic residency.