Trends in Sex and Racial/Ethnic Diversity in Applicants to Surgery Residency and Fellowship Programs

Representation of women and minority populations remains low in surgery. In 1964, 93% of all US medical students were male and 97% were non-Hispanic white.¹ Women were only recognized in surgery in the late 20th century.² Today, women make up less than 25% of multiple surgical specialties.³ African American and Hispanic American individuals each compose about only 3% to 4% of academic surgical faculty.⁴ We investigated the trends in sex and racial/ethnic diversity of the applicant pool to US surgical residency and fellowship programs throughout the past decade.

Applicant and US medical school graduating class demographics were collected from the Electronic Residency Application Service database and Association of American Medical Colleges records. We included Accreditation Council for Graduate Medical Education–accredited surgical residencies and fellowships from January 2008 to December 2018. In each surgical specialty and graduating class, the number of male, female, and total applicants/graduates were collected. Data on self-reported applicant/graduate race/ethnicity were categorized by Asian, black/African American, Hispanic, white, American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, other, and unknown race. This study was exempt from review by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board because the data were publicly available and deidentified. Trends were then evaluated with a Cochrane-Armitage test with α set at .05. Two-sided P values were used with a significance threshold of .05. Analysis took place from March to June 2019.

The percentage of US female medical graduates remained relatively stable from 46% (7028 of 15 227) in 2008 to 47% (9260 of 19 533) in 2018 (χ² = 15.44; P < .001). There was an increase in female applicants to surgical residency programs (Table 1), including integrated thoracic surgery (8 of 63 [13%] to 50 of 185 [27%]; χ² = 18.31; P < .001), integrated vascular surgery (18 of 112 [16%] to 106 of 392 [27%]; χ² = 10.33; P = .001), categorical general surgery (1211 of 4429 [27%] to 1636 of 4261 [38%]; χ² = 188.41; P < .001), and urology (130 of 532 [24%] to 128 of 462 [28%]; χ² = 4.61; P = .03) programs. Female applicants to orthopedics remained low (193 of 1360 [14%] to 226 of 1387 [16%]; χ² = 8.77; P = .003). There was no decrease in female applicants to any surgical subspecialty residency program from 2008 to 2018.

For surgical fellowship programs (Table 1), there was an increase in the percentage of female applicants to colorectal (32 of 113 [28%] to 57 of 130 [44%]; χ² = 5.03; P = .03) and pediatric surgery (32 of 64 [50%] to 44 of 82 [54%]; χ² = 9.43; P = .002). The trend was not significant for female applicants to vascular (24 of 131 [18%] to 38 of 126 [30%]; χ² = 2.85; P = .09), thoracic (14 of 108 [13%] to 32 of 122 [26%]; χ² = 3.53; P = .06), and plastic surgery fellowships (111 of 342 [32%] to 47 of 122 [39%]; χ² = 3.14; P = .08).

In US medical school graduating classes, there was a significant increase in Asian (3324 [22%] to 4660 [24%]; χ² = 4.98; P = .02) and Hispanic (1187 [8%] to 1760 [9%]; χ² = 88.84; P < .001) graduates. There was a corresponding decrease in black (1113 [7%] to 1280 [6.5%]; χ² = 49.87; P < .001) and white (10 358 [68%] to 12 186 [62%]; χ² = 427.11; P < .001) graduates. Race/ethnicity–related changes in the applicants varied (Table 2). A majority of specialties displayed no significant change in Hispanic and black applicants and a decrease in the percentage of Asian applicants to surgical residency and fellowship programs.

Increasing diversity in graduating US medical school classes may not necessarily translate to increasing diversity in the surgical training program applicant pool. The relative increase in graduating female medical students was outpaced by the increase in female applicants to surgical training programs. Despite significant increases, the percentage of female surgical applicants was not equivalent to female medical school graduates except for pediatric and colorectal surgery. Race/ethnicity variations were not reflected either positively or negatively in the surgical specialty applicant pool.

Recruitment strategies and factors influencing career choice are areas for further investigation. Addressing potential barriers⁵ and increasing mentorship of medical students⁶ may foster a more diverse interest in surgery.

This study is focused on the analysis of a specific 10-year period. Limitations include lack of sex and race/ethnicity data in the Electronic Residency Application Service database for international graduates. Additionally, applicants can select multiple races/ethnicities when applying for residency/fellowship. We corrected for this possibility by calculating race/ethnicity percentages from the total number of applicants rather than the total responses.

Accepted for Publication: March 13, 2020.

Corresponding Author: Issam Koleilat, MD, Division of Vascular and Endovascular Surgery, Montefiore Medical Center, 3400 Bainbridge Ave, 4th Floor, Bronx, NY 10467 (ikoleila@montefiore.org).

Published Online: May 27, 2020. doi:10.1001/jamasurg.2020.1018

Author Contributions: Ms Choinski and Dr Gao had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Choinski, Indes, Phair, Denesopolis, Koleilat.

Acquisition, analysis, or interpretation of data: Choinski, Lipsitz, Indes, Phair, Gao, Denesopolis, Koleilat.

Drafting of the manuscript: Choinski, Lipsitz, Phair, Koleilat.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Choinski, Gao, Denesopolis.

Administrative, technical, or material support: Indes, Denesopolis.

Supervision: Lipsitz, Indes, Phair, Denesopolis, Koleilat.

Conflict of Interest Disclosures: Dr Koleilat reports other support from Empire BlueCross BlueShield, eHealth Connect, Doximity, and Medline outside the submitted work. No other disclosures were reported.