Geographic retention and gender-based trends among orthopedic shoulder and elbow surgeons in the United States.

BACKGROUND: Regional variations in surgical training may influence where physicians establish clinical practice. In the competitive field of shoulder and elbow surgery, the impact of training location on practice patterns remains unclear. As shoulder arthroplasty volumes continue to rise and rotator cuff disease remains a common musculoskeletal complaint among older patients, equitable access to trained shoulder specialists is paramount. A deeper understanding of these trends may help identify regions that better train and retain subspecialists and inform strategies to improve geographic and gender representation.

METHODS: This study included shoulder and elbow surgeons identified through the American Shoulder and Elbow Surgeons database. Training and practice locations-medical school, residency, fellowship, and current employment were categorized using U.S. Census regions (Northeast, South, Midwest, West, international). Residency programs were also ranked according to the top 25 orthopedic hospitals listed in U.S. News & World Report. Publicly available sources were used to collect demographic and professional data. Descriptive statistics and chi-square analyses assessed geographic retention, and subgroup analyses evaluated differences by gender.

RESULTS: A total of 752 shoulder and elbow surgeons were identified: 50 (6.6%) were female and 702 (93.4%) were male. Surgeons were significantly more likely to practice in the same region where they completed residency (range: 44.1%-77.0%, P < .001), medical school (36.8%-70.4%, P < .001), and to a lesser extent, fellowship (21.9%-68.7%, P < .001). In the Northeast, retention following residency (77.0%) and fellowship (68.7%) was especially high (P < .001). In contrast, fellowship retention in the Midwest was the lowest (21.9%, P = .002). Female surgeons were more likely to remain in the Northeast after fellowship (32.0% vs. 20.2% for males, P = .048). In comparison, male surgeons were significantly more likely to remain in the Midwest after residency (10.5% vs. 0%, P = .016). Female representation was highest in the Northeast (9.1%) and lowest in the West (0.7%), though these regional differences did not reach statistical significance (P > .05).

CONCLUSION: Geographic retention among shoulder and elbow surgeons was highest following residency and medical school and lowest after fellowship, where retention varied widely by region. The Northeast consistently demonstrated the highest retention across training stages, whereas the Midwest had the lowest retention after fellowship. Sex-based differences were also observed, with greater retention of female surgeons in the Northeast after fellowship and no female retention in the Midwest after residency. These findings highlight consistent regional and sex-based differences in geographic retention across training stages.