Geographic Disparities and Workforce Trends in Orthopaedic Surgery: Potential Impact of the ACGME Merger on DO and MD Distribution.

Abstract

Geographic access to orthopaedic surgery remains limited in nonmetropolitan regions, where over half of US counties lack an orthopaedic surgeon. Osteopathic physicians (DOs) are nearly twice as likely as allopathic physicians (MDs) to practice in these areas, making them a key component of the rural surgical workforce. However, their representation in orthopaedic training has declined since the ACGME-AOA merger. This cross-sectional national study used 2022 Area Health Resource Files, National Residency Matching Program Match data (2020-2024), and USDA Rural-Urban Continuum Codes (RUCC) to evaluate workforce distribution and match outcomes. Statistical analysis included chi-square testing and odds ratios to assess nonmetropolitan representation by degree and state. Of 30,243 orthopaedic surgeons, 92.9% practiced in metropolitan counties and 7.1% in nonmetropolitan areas. Among DOs, 12.5% practiced in nonmetropolitan regions compared with 6.9% of MDs (OR = 1.92; 95% CI: 1.67-2.19). Eleven states showed significantly higher odds of DOs practicing in nonmetropolitan counties, 9 of these states with longstanding in-state osteopathic schools. From 2010 to 2022, DO presence in nonmetropolitan areas increased by 59%, nearly double the rate of MDs. Despite these contributions, DO match rates in orthopaedic surgery declined from 63.3% to 45.7% between 2020 and 2024, widening the DO-MD gap. DOs play an important role in orthopaedic coverage, as a percentage of their total, in nonmetropolitan communities. Declining match rates raise concerns about the sustainability of this workforce, particularly in states where DOs help maintain surgical access. Structural reforms in training pathways and residency selection may help preserve geographic workforce diversity. Targeted strategies, such as rural training programs, holistic applicant evaluation, and state-specific recruitment efforts, may strengthen access to musculoskeletal care in underserved regions and support a more equitable orthopaedic workforce.