International Medical Graduate Orthopaedic Residents Show Higher Research Productivity Than United States Graduate Peers Before and During Residency

International Medical Graduate Orthopaedic Residents Show Higher Research Productivity Than United States Graduate Peers Before and During Residency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article International Medical Graduate Orthopaedic Residents Show Higher Research Productivity Than United States Graduate Peers Before and During Residency James Stuart MacLeod, Freddy Jacome, Hadel Mansour, Michael Lee, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5320459/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose International Medical Graduates (IMGs) have lower match rates than their United States (U.S.)-trained Doctor of Allopathic Medicine (MD) and Doctor of Osteopathic Medicine (DO) peers. This study aims to more completely elucidate the research accomplishments required for IMGs to match into orthopaedic residency and to compare their academic productivity during residency to that of U.S. MD and DO graduates. Methods Data from orthopaedic-related journals and ACGME-accredited residency programs were extracted in July of 2024 using Python. Variables included: residency year, publications, first-author publications, citations, journals, h-index, medical school type, and the medical school and residency program locations. Results Prior to residency, the 56 matched IMGs had a mean of 32.8 publications, 9.8 first-author publications, and 517.1 citations. Matched U.S. MDs had an average of 3.7 publications, 1.1 first-author publications, and 61.0 citations while DO matched applicants had an average of 3.7 publications, 1.0 first-author publications, and 5.6 citations. During residency, IMG orthopaedic residents averaged 5.2 publications per year and 16.6 citations per year. U.S. MD residents averaged 1.3 publications per year and 3.6 citations per year, while DO residents averaged 0.55 publications per year and 1.1 citations per year. The h-index averaged 9.8 for IMGs, 2.2 for U.S. MDs and 0.7 for DOs. All comparisons for IMGs vs U.S. MDs and IMGs vs DOs yielded P < 0.0001. Conclusion These findings highlight the significant differences in research output between IMGs and their U.S.-trained counterparts in orthopaedic surgery, and show that these differences continue throughout residency. IMG international education training publication research orthopaedic surgery Figures Figure 1 Figure 2 Introduction International Medical Graduates (IMGs) make up over 25% of physicians practicing in United States [1], but the path to practicing as a physician in the United States as a foreign trained doctor is challenging [2, 3]. The proportion of practicing U.S. physicians who are IMGs varies significantly by specialty. Primary care specialties and medical subspecialties have the highest percentage of IMGs (up to 51%, nephrology), while surgical subspecialists and dermatology have lower percentages (as low as 4.1% for orthopaedic surgery sports medicine) [4]. These trends in practicing physicians parallel findings in United States residency programs where 22.9% of residents are IMGs [5]. Surgical subspecialties traditionally have the lowest match rates, with higher applicant standardized exam scores and research metrics [6, 7]. Orthopaedic surgery is considered one of the most competitive specialties, with the lowest percentage of IMG residents at 1.3% and has experienced a rapid increase in applicant research output prior to residency [5, 8]. The rate of IMGs matching into orthopaedic surgery has declined from 3% in 2008 to less than 1% in 2024. Precisely identifying the application characteristics that distinguish IMGs who successfully match into orthopaedic surgery is important and may help increase IMG success. Additionally, investigation of if the exceptional productivity of IMG applicants that Match into orthopaedic surgery continues into residency is lacking. For United States allopathic seniors, factors like Alpha Omega Alpha status, ranking of medical school attended, and board exam scores have been shown to influence match outcomes [9]. However, for IMGs, metrics like Alpha Omega Alpha status and medical school ranking are not considered in their applications, leaving board exam scores and research productivity as key factors. Literature in other specialties, particularly neurosurgery and plastic surgery, has shown increased research productivity of matched IMGs compared to their United States counterparts prior to residency [2, 3, 10]. Predictive factors for IMGs matching into orthopaedic surgery are less studied, but data indicates that matched IMGs in orthopaedics typically match an average of 4.66 years after medical school graduation and have substantially more publications at the time of application than other applicant groups [11]. This study analyzes differences in research output before and during residency for IMGs and United States medical students who have successfully matched into orthopaedic surgery. This study aims to elucidate the research accomplishments required for IMGs to match into orthopaedic residency and to compare their academic productivity during residency to that of U.S. Doctor of Allopathic Medicine (MD) and Doctor of Osteopathic Medicine (DO) graduates. We hypothesized that matched IMGs have higher research output compared to their United States peers both before and during residency. Materials and Methods Resident Cohort The Accreditation Council for Graduate Medical Education (ACGME) Accredited Programs and Sponsoring Institutions Search and Reports site was used to generate a list of the 208 ACGME-accredited orthopaedic surgery training programs. A complete list of current orthopaedic surgery residents from postgraduate years (PGY) 1–5 and research year residents was acquired from publicly available program websites and social media pages in July of 2024. All publicly available websites were accessed between February and April 2024, reflecting residents that started from 2019 to 2023. Programs were excluded if their websites were not updated to reflect residents in this time frame. The total number of residents per program was compared to NRMP data from 2019 to 2023 and the Residency Explorer website to data accuracy. Ethical approval and consent to participate was confirmed as not required for this study as all data was obtained from publicly accessible resources. No contact was made with any residents during the data collection process. Demographic information including name, medical school, medical school location, residency program, residency program location, degree, and postgraduate year were collected for each resident. This information was collected through a combination of publicly available websites including program websites, Doximity, LinkedIn, Google, Twitter, and Instagram. Python scripts were developed to cross-reference resident names with their graduation year and medical school name, considering variations in names and potential nicknames. This additional step ensured that our database accurately reflected resident publication data, even when name variations were reported on program websites. The collected resident data was then subdivided based on type of medical school attended: United States Allopathic, MD, United States Osteopathic, DO, or International Medical Graduate. Medical school location and location of program matched at are displayed on a world map at a website created by the authors: https://freddyjacomeuic.github.io/IMGOrthomap/IMG_Interactive_Map.html . Publication Data Bibliometric data was systematically collected using Elsevier Scopus Application Programming Interfaces (API), specifically through the Abstract Retrieval, Scopus Search, and Author Search APIs. An initial search was done utilizing a combination of resident names, medical school attended, and residency program. Residents with no publications underwent additional queries incorporating their name and all orthopaedic surgery research fellowship programs (obtained from orthogate.com). A final search included the resident name and all orthopaedic surgery publications during the 2011–2024 time-period. If no publications were found for a resident after these queries, they were considered to have zero publications. The data collected included the total number of publications, first author publications, and h-index. Additional metadata extracted included the source type (such as books, journals, letters, etc.), citation counts, journal name, total number of authors, date of publication, author order, and author affiliations. Publications published before September 1st of the year an individual started residency were categorized as pre-residency data. A cutoff of September 1st was used with the assumption that residents rarely publish in the first few months of residency and most published work from medical school that would be included in the resident’s application was assumed to be finished by this time. Pre-residency h-index was manually calculated using a python script by subtracting out all manuscripts that were published after the individual started residency. Statistical Analysis Publication numbers for each resident subgroup (U.S. MD, DO, and IMG) were compared using mean and standard deviations. Publications during residency were averaged to calculate the number per year of residency, avoiding comparisons between senior residents and interns. To assess the quality of publications, we utilized each resident’s h-index as a proxy, given its reputation as a metric that combines productivity and citation impact into a single score. Descriptive statistics summarized the distributions of total publications (quantity) and h-index (quality). Unpaired two-tailed t-test were used for P values. Results The study included 56 IMGs (1.3%), 3747 United States MDs (85.6%) and 572 DOs (13.1%). To our understanding, no residents were excluded. Among IMGs, 16.1% of residents were female, among U.S. MDs, 22.9% were female, and for DOs, 11.7% were female. The Caribbean was the most common region for matched IMGs to have completed medical school (30.4%), with Grenada being the country with the most matched trainees (17.9%). The proportion of Canadian residents was surprisingly low at under 2%, Table 1 . The states with the most IMG matches were Massachusetts (12.5%) and Maryland (10.7%), Fig. 1 , Table 2 . The two programs with the highest number of IMG matches were the Harvard Combined Orthopaedic Residency (8.9%) and Johns Hopkins (7.1%). Table 1 Table listing country of medical school attended for n = 56 international medical graduate orthopaedic surgery residents in the United States. Medical School Region Country United States Orthopaedic Residents (% of IMGs), n = 56 Caribbean 17 (30.4) Saint Vincent and the Grenadines 1 (1.8) Grenada 10 (17.9) Antigua and Barbuda 3 (5.4) Saba 2 (3.6) St. Kitts & Nevis 1 (1.8) South America 6 (10.7) Venezuela 4 (7.1) Argentina 1 (1.8) Colombia 1 (1.8) North America 1 (1.8) Canada 1 Europe 13 (23.2) Ireland 2 (3.6) Belgium 2 (3.6) United Kingdom 5 (8.9) Hungary 1 (1.8) Greece 1 (1.8) Austria 1 (1.8) Netherlands 1 (1.8) Africa 2 (3.6) Egypt 2 Asia and Middle East 12 (21.4) India 3 (5.4) Iran 1 (1.8) Lebanon 5 (8.9) Singapore 1 (1.8) Pakistan 1 (1.8) Oceania 5 (8.9) Australia 5 IMG, international medical graduate. Table 2 States where the most IMGs matched. State Number matched (% of all matched IMGs) Massachusetts 7 (12.5) Maryland 6 (10.7) Missouri 5 (8.9) Ohio 5 (8.9) New York 5 (8.9) Pennsylvania 4 (7.1) New Jersey 4 (7.1) Florida 4 (7.1) Georgia 3 (5.4) Louisiana 2 (3.6) New Mexico 2 (3.6) California 2 (3.6) North Carolina 2 (3.6) Rhode Island 1 (1.8) Alabama 1 (1.8) Colorado 1 (1.8) Tennessee 1 (1.8) Arizona 1 (1.8) IMG, international medical graduate. IMGs who matched into orthopaedic surgery had nearly ten-fold higher academic productivity than U.S. MDs and DOs prior to residency with an average of 32.8 orthopaedic related publications (± 29.0), Fig. 2 , 10 first-author orthopaedic publications (± 13.2), and 517.1 citations (± 678.0). In contrast, matched U.S. MDs had an average of 3.7 orthopaedic publications (± 7.0), 1.1 orthopaedic first-author publication (± 2.4), and 61.0 citations (± 533.2). Matched DO applicants averaged 3.7 orthopaedic publications (± 7.2), 1.0 orthopaedic first-author publication (± 2.4), and 5.6 citations (± 23.2). Differences in publications, first author manuscripts, and citations between IMGs and US MDs, and between IMGs and DOs, were all significant with P = < 0.0001. The four most common journals in which IMG-matched applicants published before residency were: Journal of Arthroplasty (10.0%), Journal of Knee Surgery (6.6%), Hand (3.3%) and Spine (3.3%), Table 3 . Table 3 Journals that IMGs most commonly published in prior to residency. Journal Name Number of Publications Journal of Arthroplasty 81 Journal of Knee Surgery 53 Hand 27 Spine 27 Spine Deformity 25 HIP International 25 Journal of the American Academy of Orthopaedic Surgeons 25 Journal of Bone and Joint Surgery 23 European Journal of Orthopaedic Surgery and Traumatology 19 Global Spine Journal 18 Journal of Pediatric Orthopaedics 17 Journal of Orthopaedic Trauma 16 Spine Journal 16 Orthopedics 14 Journal of Shoulder and Elbow Surgery 14 Seminars in Arthroplasty JSES 11 Orthopaedic Journal of Sports Medicine 11 Journal of Orthopaedics 11 Clinical Orthopaedics and Related Research 10 Journal of Hand and Microsurgery 10 Injury 10 Arthroplasty Today 9 Clinical Spine Surgery 9 Journal of Surgical Oncology 8 JSES International 8 JAAOS Global Research and Reviews 8 Physician and Sports Medicine 8 JBJS Reviews 7 World Neurosurgery 7 Neurospine 7 Journal of Hand Surgery Global Online 7 Ochsner Journal 7 Arthroscopy Techniques 7 Archives of Bone and Joint Surgery 7 JBJS Case Connector 7 Archives of Orthopaedic and Trauma Surgery 6 Journal of Hand Surgery 6 Scientific Reports 6 International Journal of Spine Surgery 6 Arthroscopy, Sports Medicine, and Rehabilitation 6 Journal of Clinical Medicine 5 Plastic and Reconstructive Surgery 5 JBJS Open Access 5 American Journal of Sports Medicine 5 Knee 5 Knee Surgery, Sports Traumatology, Arthroscopy 5 IMG, international medical graduate; JBJS, Journal of Bone and Joint Surgery; JSES, Journal of Shoulder and Elbow Surgery; JAAOS, Journal of the Academy of Orthopaedic Surgeons. Significant differences were also found in academic productivity between IMGs and their U.S.-trained counterparts during orthopaedic surgery residency. IMG orthopaedic surgery residents averaged 5.2 publications per year (± 4.9) and 16.6 citations per year (± 22.2), Fig. 2 . In contrast, U.S. MD residents averaged 1.3 publications per year (± 2.4) and 3.6 citations per year (± 10.4), while Doctor of Osteopathic Medicine (DO) residents averaged 0.55 publications per year (± 1.5) and 1.1 citations per year (± 3.8). Differences between IMGs and U.S. MDs, as well as between IMGs and DOs, were significant ( P = < 0.0001). Research quality based on h-index showed averages of 9.8 for IMGs (± 6.9), 2.2 for U.S. MDs (± 3.0) and 0.7 for DOs (± 1.9) with P = < 0.0001 for IMGs vs U.S. MDs and IMGs vs DOs. Discussion The major findings of this study are threefold: firstly, IMGs exhibit significantly higher research output than their U.S. MD and DO counterparts before matching into U.S. orthopaedic surgery residency programs. The quantitative findings of the present study are the most rigorous performed to date. Secondly, this trend persists through residency, with IMGs producing more research than their US-educated peers. Thirdly, the regions with the highest number of IMGs matched into orthopaedic surgery residencies are the Caribbean, Europe, and Oceania, while the states with the most matched IMGs are Massachusetts and Maryland. Number of publications, first author publications, citations, and h-index were all significantly higher for matched IMG orthopaedic surgery residents than their U.S. trained peers. Academic productivity within orthopaedics before residency was nearly ten-fold higher for IMGs than both U.S. MDs and DOs. These findings parallel those of Fares et al., who reported that matched orthopaedic IMGs averaged 26.3 publications before residency, while our study found an average of 32.8 [11]. This study expands on their analysis by including IMG publication data of IMGs during residency, assessing research quality using the h-index, and including a complete sample of matched IMGs (56 vs 44). Similar trends in research productivity among IMGs have been observed in other surgical subspecialties, such as neurosurgery[2] and plastic surgery [3]. Mignucci-Jiménez et al. demonstrated that in neurosurgery, program directors have higher expectations for IMGs to complete research prior to residency, which possibly also holds true in orthopaedics [2]. The orthoapedic journal most frequently published by IMGs before residency was the Journal of Arthroplasty, it is unclear why this is the case. As medical education increasingly emphasizes diversity, IMGs represent an invaluable resource in addressing these needs and serving the diverse American public [12]. This underscores the need for further research on strategies to enhance IMGs success in the orthopaedic residency match. Future studies could include program director responses on expectations for IMG applicants, similar to published neurosurgery studies [2]. We found that the trend of increased IMG research productivity before residency continues through residency, where IMGs produce more research than their U.S. educated peers. IMGs published nearly four-fold as many publications and received nearly four times as many citations per year of residency compared to U.S. MDs and DOs. This finding supports the increased inclusion of vetted IMGs in U.S. residencies given their substantial academic productivity. Mignucci-Jiménez et al. reported a decrease IMG research productivity during residency compared to before residency [2]. This comparison was not possible to perform in the current study as we cannot calculate publications per year prior to residency without exact applicant timelines of research years and medical education. However, it appears that IMG residents maintain a comparable level of productivity despite the increased clinical burden [13]. Fares et al. reported that, on average, 4.66 years passed between completing medical school and starting residency for matched IMGs [11]. While it is evident that IMGs in orthopaedics are generally more academically productive than their peers before and during residency, it is uncertain to what degree this productivity continues post-residency. Further investigation is needed into the research productivity of IMGs during fellowship and as practicing surgeons. Additional studies could aim to determine more precise research activity timelines for IMGs before matching, including the duration of research and training prior to the U.S. match. The most common countries where matched orthopaedic IMGs completed medical school were: Grenada (17.9%), Australia (10.7%), Lebanon (8.9%) and the United Kingdom (8.9%). These results differ from Fares et al., who reported Ireland and the United Kingdom as the most common countries [11]. We found the same number of residents from European medical schools but included a total of 56 IMGs compared to their 44, explaining the difference in results. While they reported 8 residents from Central America and Caribbean medical schools, we found 23. Our results further provide guidance to applicants and a clearer picture of the origins of IMGs in orthopaedics. It is unsurprising that the Caribbean had the higher proportion of matched applicants given its proximity to and familiarity with the US medical education system [14]. Australia also had a high number of successful applicants (8.9%), but all of these applicants attended the University of Queensland Ochsner Clinical School, which completes their third and fourth year clinical rotations in the United States [15], similar to Caribbean schools thus giving these groups an advantage over other IMGs. Our findings demonstrate the geographical distribution of matched applicants in orthopaedic surgery, with the Caribbean and Europe being the regions with the most matched residents, and Massachusetts and Maryland being the states with the most matched IMGs. These results are influenced by high numbers of IMGs at Harvard Combined Orthopaedic Residency Program (HCORP) and Johns Hopkins Orthopaedic residency program. Given the success of multiple students from Queensland University’s program, future studies should evaluate the viability of a hybrid medical school curriculum outside of the Caribbean as a potential alternative for international students aiming to enter U.S. residencies. Overall, this study found that IMGs have significantly higher research activity than their U.S. MD and DO counterparts before matching into U.S. orthopaedic surgery residency programs and that this trend continues through residency. Despite the distinction of successful IMG applicants in research, program directors must still carefully consider the potential for IMGs to succeed in their programs, given unique challenges they face, including visa status, work authorization, travel restrictions, and others. Limitations There are several limitations of this review. Firstly, only research publications in relation to orthopaedic surgery were included in this analysis. Research in other fields may influence matching and was not assessed. Secondly, our assessment did not include accepted abstracts, posters or podium presentations. Thirdly, despite our best efforts, there may be IMGs missing or falsely included due to errors in the public domain data used. Fourthly, we did not include several factors that have been shown to play a large role in matching into U.S. residency including: letters of recommendation, board exam scores, interview performance, and medical school academic performance. Fifthly, we did not account for distribution or variance when calculating P values using unpaired t-tests. Finally, our study does not include a subgroup of foreign students who completed medical school in the United States, but are functionally similar to IMGs given their potential need for visa sponsorship. Conclusion These findings highlight the significant differences in research output between IMGs and their U.S.-trained counterparts in orthopaedic surgery, and suggest that these differences continue throughout residency. Declarations Funding Declaration : This research received no specific grant or funding. Human Ethics and Consent to Participate Declaration Not applicable. Author Contribution JSM and FJ contributed to the study conception and design. Material preparation, data collection and analysis were performed by FJ, FA, OL and AC. The first draft of the manuscript was written by JSM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Kaushal, N., R. Kaestner, and T. Rigzin, (2022) Foreign-Trained Physicians in the United States: A Descriptive Profile. Medical Care Research and Review, 79 (5): p. 717-730. https://doi.org/10.1177/10775587211066994 Mignucci-Jiménez, G., et al., (2022) Analyzing international medical graduate research productivity for application to US neurosurgery residency and beyond: A survey of applicants, program directors, and institutional experience. Frontiers in Surgery, 9 . https://doi.org/10.3389/fsurg.2022.899649 Kokosis, G., et al., (2018) International Medical Graduates in the US Plastic Surgery Residency: Characteristics of Successful Applicants. Eplasty, 18 : p. e33. Active Physicians Who Are International Medical Graduates (IMGs) by Specialty, 2021 , A.M. Association, Editor. (2021) AMA Physician Masterfile. ACGME residents and fellows who are international medical graduates (IMGs) by specialty , N.G.C.i.G.T. ® , Editor. (2022) American Medical Association. Nasser, J.S., et al., (2023) Matching into competitive surgical residencies: predictors of success. Med Educ Online, 28 (1): p. 2189558. https://doi.org/10.1080/10872981.2023.2189558 Gauer, J.L. and J.B. Jackson, (2017) The association of USMLE Step 1 and Step 2 CK scores with residency match specialty and location. Med Educ Online, 22 (1): p. 1358579. https://doi.org/10.1080/10872981.2017.1358579 Abbas, A.M., et al., (2024) Orthopedic Surgery Matched Applicants Are Publishing More: A Bibliometric Analysis of Research Output. Cureus, 16 (3): p. e56210. https://doi.org/10.7759/cureus.56210 Schrock, J.B., et al., (2017) A Comparison of Matched and Unmatched Orthopaedic Surgery Residency Applicants from 2006 to 2014: Data from the National Resident Matching Program. JBJS, 99 (1). https://doi.org/10.2106/jbjs.16.00293 Vought, R., et al., (2024) Analysis of neurosurgery resident research activity in the United States. J Neurosurg, p. 1-8. https://doi.org/10.3171/2024.2.jns232752 Fares, M.Y., et al., (2024) International Medical Graduates in US Orthopedic Residency Programs: A Comprehensive Analysis. R I Med J. 107 (2): p. 40-43. McElvaney, O.J. and G.T. McMahon, (2024) International Medical Graduates and the Physician Workforce. JAMA, 332 (6): p. 490-496. https://doi.org/10.1001/jama.2024.7656 Bohm, K.C., et al., (2016) Orthopedic Residency: Are Duty Hours Predictive of Performance? J Surg Educ, 73 (2): p. 281-5. https://doi.org/10.1016/j.jsurg.2015.09.015 Duvivier, R.J., E. Wiley, and J.R. Boulet, (2019) Supply, distribution and characteristics of international medical graduates in family medicine in the United States: a cross-sectional study. BMC Fam Pract, 20 (1): p. 47. https://doi.org/10.1186/s12875-019-0933-8 Ochsner Years 3 & 4 . [cited 2024 8/10/2024]; Available from: https://medical-school.uq.edu.au/about/clinical-schools/ochsner-clinical-school/ochsner-years-3-and-4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Feb, 2025 Reviewers invited by journal 26 Oct, 2024 Editor assigned by journal 25 Oct, 2024 Submission checks completed at journal 25 Oct, 2024 First submitted to journal 23 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5320459","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370757996,"identity":"246ad5d8-7b02-4aac-9915-e282eaa41e51","order_by":0,"name":"James Stuart MacLeod","email":"data:image/png;base64,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","orcid":"","institution":"Northwestern University","correspondingAuthor":true,"prefix":"","firstName":"James","middleName":"Stuart","lastName":"MacLeod","suffix":""},{"id":370757997,"identity":"e3ce04d0-006d-4f7d-8299-6467b198c2ea","order_by":1,"name":"Freddy Jacome","email":"","orcid":"","institution":"University of Illinois at Chicago","correspondingAuthor":false,"prefix":"","firstName":"Freddy","middleName":"","lastName":"Jacome","suffix":""},{"id":370757998,"identity":"b0054b1e-5c3b-4398-95f4-77d68637ef0c","order_by":2,"name":"Hadel Mansour","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Hadel","middleName":"","lastName":"Mansour","suffix":""},{"id":370757999,"identity":"cd4605c5-7927-4374-9764-5c4b410c447c","order_by":3,"name":"Michael Lee","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Lee","suffix":""},{"id":370758000,"identity":"409dd914-57e4-42e8-afb8-5609a0d0946f","order_by":4,"name":"Frances Akwuole","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Frances","middleName":"","lastName":"Akwuole","suffix":""},{"id":370758001,"identity":"86d20068-1a85-459c-8fae-a2a33d70d605","order_by":5,"name":"Sia Cho","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Sia","middleName":"","lastName":"Cho","suffix":""},{"id":370758002,"identity":"0d73e8b9-4608-4c75-acd2-adc799c7b189","order_by":6,"name":"Justin Lee","email":"","orcid":"","institution":"Rutgers School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"","lastName":"Lee","suffix":""},{"id":370758003,"identity":"dbcc923e-7cd8-4deb-9b8d-ebd8422571d0","order_by":7,"name":"Owen Lema","email":"","orcid":"","institution":"University of Illinois at Chicago","correspondingAuthor":false,"prefix":"","firstName":"Owen","middleName":"","lastName":"Lema","suffix":""},{"id":370758005,"identity":"bae99ae6-7dd8-4f5c-a3e3-0c26e9389f0e","order_by":8,"name":"Avani Chopra","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Avani","middleName":"","lastName":"Chopra","suffix":""},{"id":370758007,"identity":"4f61f11d-a960-4562-a0f6-599b6be2b263","order_by":9,"name":"Yianni Bakaes","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Yianni","middleName":"","lastName":"Bakaes","suffix":""},{"id":370758008,"identity":"183a884b-a8f6-403d-a68b-9b3ed535af1b","order_by":10,"name":"Sabrina Painter","email":"","orcid":"","institution":"University of Wisconsin–Milwaukee","correspondingAuthor":false,"prefix":"","firstName":"Sabrina","middleName":"","lastName":"Painter","suffix":""},{"id":370758009,"identity":"63a271b3-27d8-4308-bde2-cb310a5205ca","order_by":11,"name":"Hayden Baker","email":"","orcid":"","institution":"Hospital for Special Surgery","correspondingAuthor":false,"prefix":"","firstName":"Hayden","middleName":"","lastName":"Baker","suffix":""},{"id":370758010,"identity":"1c2a808e-ed85-44be-8660-522f5975c521","order_by":12,"name":"Alfonso Mejia","email":"","orcid":"","institution":"University of Illinois at Chicago","correspondingAuthor":false,"prefix":"","firstName":"Alfonso","middleName":"","lastName":"Mejia","suffix":""}],"badges":[],"createdAt":"2024-10-23 16:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5320459/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5320459/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69080243,"identity":"5ad1d842-a685-4ad4-9bcc-40203346e280","added_by":"auto","created_at":"2024-11-15 11:48:39","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":421942,"visible":true,"origin":"","legend":"\u003cp\u003eMap demonstrating location of international medical graduate medical school (red) and orthopaedic surgery residency program matched at (blue); n=56. The following website, created by the authors, allows for interactive analysis: https://freddyjacomeuic.github.io/IMGOrthomap/IMG_Interactive_Map.html.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5320459/v1/04cb3b8643a0aa4d54c0177a.jpeg"},{"id":69080242,"identity":"15529fd4-ec5a-4109-b663-754e99008a37","added_by":"auto","created_at":"2024-11-15 11:48:39","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71578,"visible":true,"origin":"","legend":"\u003cp\u003eBox plots of A. international medical graduate pre-residency and B. during residency publications, where x represents the mean; n=56.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5320459/v1/51b60e857d495134108d7caf.jpeg"},{"id":69081059,"identity":"0e49377b-3dea-44fd-8f59-bd5f67991e17","added_by":"auto","created_at":"2024-11-15 11:56:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1094737,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5320459/v1/4a757a15-c4e5-4894-a212-918345d4e781.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"International Medical Graduate Orthopaedic Residents Show Higher Research Productivity Than United States Graduate Peers Before and During Residency","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInternational Medical Graduates (IMGs) make up over 25% of physicians practicing in United States [1], but the path to practicing as a physician in the United States as a foreign trained doctor is challenging [2, 3]. The proportion of practicing U.S. physicians who are IMGs varies significantly by specialty. Primary care specialties and medical subspecialties have the highest percentage of IMGs (up to 51%, nephrology), while surgical subspecialists and dermatology have lower percentages (as low as 4.1% for orthopaedic surgery sports medicine) [4]. These trends in practicing physicians parallel findings in United States residency programs where 22.9% of residents are IMGs [5]. Surgical subspecialties traditionally have the lowest match rates, with higher applicant standardized exam scores and research metrics [6, 7]. Orthopaedic surgery is considered one of the most competitive specialties, with the lowest percentage of IMG residents at 1.3% and has experienced a rapid increase in applicant research output prior to residency [5, 8]. The rate of IMGs matching into orthopaedic surgery has declined from 3% in 2008 to less than 1% in 2024.\u003c/p\u003e \u003cp\u003ePrecisely identifying the application characteristics that distinguish IMGs who successfully match into orthopaedic surgery is important and may help increase IMG success. Additionally, investigation of if the exceptional productivity of IMG applicants that Match into orthopaedic surgery continues into residency is lacking. For United States allopathic seniors, factors like Alpha Omega Alpha status, ranking of medical school attended, and board exam scores have been shown to influence match outcomes [9]. However, for IMGs, metrics like Alpha Omega Alpha status and medical school ranking are not considered in their applications, leaving board exam scores and research productivity as key factors. Literature in other specialties, particularly neurosurgery and plastic surgery, has shown increased research productivity of matched IMGs compared to their United States counterparts prior to residency [2, 3, 10]. Predictive factors for IMGs matching into orthopaedic surgery are less studied, but data indicates that matched IMGs in orthopaedics typically match an average of 4.66 years after medical school graduation and have substantially more publications at the time of application than other applicant groups [11].\u003c/p\u003e \u003cp\u003eThis study analyzes differences in research output before and during residency for IMGs and United States medical students who have successfully matched into orthopaedic surgery. This study aims to elucidate the research accomplishments required for IMGs to match into orthopaedic residency and to compare their academic productivity during residency to that of U.S. Doctor of Allopathic Medicine (MD) and Doctor of Osteopathic Medicine (DO) graduates. We hypothesized that matched IMGs have higher research output compared to their United States peers both before and during residency.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResident Cohort\u003c/h2\u003e \u003cp\u003eThe Accreditation Council for Graduate Medical Education (ACGME) Accredited Programs and Sponsoring Institutions Search and Reports site was used to generate a list of the 208 ACGME-accredited orthopaedic surgery training programs. A complete list of current orthopaedic surgery residents from postgraduate years (PGY) 1\u0026ndash;5 and research year residents was acquired from publicly available program websites and social media pages in July of 2024. All publicly available websites were accessed between February and April 2024, reflecting residents that started from 2019 to 2023. Programs were excluded if their websites were not updated to reflect residents in this time frame. The total number of residents per program was compared to NRMP data from 2019 to 2023 and the Residency Explorer website to data accuracy.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003ewas confirmed as not required for this study as all data was obtained from publicly accessible resources. No contact was made with any residents during the data collection process. Demographic information including name, medical school, medical school location, residency program, residency program location, degree, and postgraduate year were collected for each resident. This information was collected through a combination of publicly available websites including program websites, Doximity, LinkedIn, Google, Twitter, and Instagram. Python scripts were developed to cross-reference resident names with their graduation year and medical school name, considering variations in names and potential nicknames. This additional step ensured that our database accurately reflected resident publication data, even when name variations were reported on program websites. The collected resident data was then subdivided based on type of medical school attended: United States Allopathic, MD, United States Osteopathic, DO, or International Medical Graduate. Medical school location and location of program matched at are displayed on a world map at a website created by the authors: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://freddyjacomeuic.github.io/IMGOrthomap/IMG_Interactive_Map.html\u003c/span\u003e\u003cspan address=\"https://freddyjacomeuic.github.io/IMGOrthomap/IMG_Interactive_Map.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePublication Data\u003c/h3\u003e\n\u003cp\u003eBibliometric data was systematically collected using Elsevier Scopus Application Programming Interfaces (API), specifically through the Abstract Retrieval, Scopus Search, and Author Search APIs. An initial search was done utilizing a combination of resident names, medical school attended, and residency program. Residents with no publications underwent additional queries incorporating their name and all orthopaedic surgery research fellowship programs (obtained from orthogate.com). A final search included the resident name and all orthopaedic surgery publications during the 2011\u0026ndash;2024 time-period. If no publications were found for a resident after these queries, they were considered to have zero publications.\u003c/p\u003e \u003cp\u003eThe data collected included the total number of publications, first author publications, and h-index. Additional metadata extracted included the source type (such as books, journals, letters, etc.), citation counts, journal name, total number of authors, date of publication, author order, and author affiliations. Publications published before September 1st of the year an individual started residency were categorized as pre-residency data. A cutoff of September 1st was used with the assumption that residents rarely publish in the first few months of residency and most published work from medical school that would be included in the resident\u0026rsquo;s application was assumed to be finished by this time. Pre-residency h-index was manually calculated using a python script by subtracting out all manuscripts that were published after the individual started residency.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003ePublication numbers for each resident subgroup (U.S. MD, DO, and IMG) were compared using mean and standard deviations. Publications during residency were averaged to calculate the number per year of residency, avoiding comparisons between senior residents and interns. To assess the quality of publications, we utilized each resident\u0026rsquo;s h-index as a proxy, given its reputation as a metric that combines productivity and citation impact into a single score. Descriptive statistics summarized the distributions of total publications (quantity) and h-index (quality). Unpaired two-tailed t-test were used for \u003cem\u003eP\u003c/em\u003e values.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 56 IMGs (1.3%), 3747 United States MDs (85.6%) and 572 DOs (13.1%). To our understanding, no residents were excluded. Among IMGs, 16.1% of residents were female, among U.S. MDs, 22.9% were female, and for DOs, 11.7% were female. The Caribbean was the most common region for matched IMGs to have completed medical school (30.4%), with Grenada being the country with the most matched trainees (17.9%). The proportion of Canadian residents was surprisingly low at under 2%, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The states with the most IMG matches were Massachusetts (12.5%) and Maryland (10.7%), Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The two programs with the highest number of IMG matches were the Harvard Combined Orthopaedic Residency (8.9%) and Johns Hopkins (7.1%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable listing country of medical school attended for n\u0026thinsp;=\u0026thinsp;56 international medical graduate orthopaedic surgery residents in the United States.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical School Region\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited States Orthopaedic Residents (% of IMGs), n\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaribbean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (30.4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSaint Vincent and the Grenadines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrenada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntigua and Barbuda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSaba\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSt. Kitts \u0026amp; Nevis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSouth America\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6 (10.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVenezuela\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArgentina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColombia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNorth America\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1 (1.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEurope\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e13 (23.2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHungary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreece\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfrica\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2 (3.6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAsia and Middle East\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e12 (21.4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLebanon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOceania\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5 (8.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIMG, international medical graduate.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStates where the most IMGs matched.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber matched (% of all matched IMGs)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassachusetts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaryland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissouri\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOhio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew York\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePennsylvania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew Jersey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlorida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeorgia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLouisiana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew Mexico\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalifornia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth Carolina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRhode Island\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlabama\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTennessee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArizona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIMG, international medical graduate.\u003c/p\u003e \u003cp\u003eIMGs who matched into orthopaedic surgery had nearly ten-fold higher academic productivity than U.S. MDs and DOs prior to residency with an average of 32.8 orthopaedic related publications (\u0026plusmn;\u0026thinsp;29.0), Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 10 first-author orthopaedic publications (\u0026plusmn;\u0026thinsp;13.2), and 517.1 citations (\u0026plusmn;\u0026thinsp;678.0). In contrast, matched U.S. MDs had an average of 3.7 orthopaedic publications (\u0026plusmn;\u0026thinsp;7.0), 1.1 orthopaedic first-author publication (\u0026plusmn;\u0026thinsp;2.4), and 61.0 citations (\u0026plusmn;\u0026thinsp;533.2). Matched DO applicants averaged 3.7 orthopaedic publications (\u0026plusmn;\u0026thinsp;7.2), 1.0 orthopaedic first-author publication (\u0026plusmn;\u0026thinsp;2.4), and 5.6 citations (\u0026plusmn;\u0026thinsp;23.2). Differences in publications, first author manuscripts, and citations between IMGs and US MDs, and between IMGs and DOs, were all significant with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001. The four most common journals in which IMG-matched applicants published before residency were: Journal of Arthroplasty (10.0%), Journal of Knee Surgery (6.6%), Hand (3.3%) and Spine (3.3%), Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJournals that IMGs most commonly published in prior to residency.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal Name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Publications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Knee Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine Deformity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIP International\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of the American Academy of Orthopaedic Surgeons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Bone and Joint Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuropean Journal of Orthopaedic Surgery and Traumatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal Spine Journal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Pediatric Orthopaedics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Orthopaedic Trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine Journal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Shoulder and Elbow Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeminars in Arthroplasty JSES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopaedic Journal of Sports Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Orthopaedics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Orthopaedics and Related Research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Hand and Microsurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthroplasty Today\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Spine Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Surgical Oncology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJSES International\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJAAOS Global Research and Reviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician and Sports Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJBJS Reviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorld Neurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurospine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Hand Surgery Global Online\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOchsner Journal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthroscopy Techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArchives of Bone and Joint Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJBJS Case Connector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArchives of Orthopaedic and Trauma Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Hand Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScientific Reports\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational Journal of Spine Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthroscopy, Sports Medicine, and Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJournal of Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic and Reconstructive Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJBJS Open Access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Journal of Sports Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee Surgery, Sports Traumatology, Arthroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIMG, international medical graduate; JBJS, Journal of Bone and Joint Surgery; JSES, Journal of Shoulder and Elbow Surgery; JAAOS, Journal of the Academy of Orthopaedic Surgeons.\u003c/p\u003e \u003cp\u003eSignificant differences were also found in academic productivity between IMGs and their U.S.-trained counterparts during orthopaedic surgery residency. IMG orthopaedic surgery residents averaged 5.2 publications per year (\u0026plusmn;\u0026thinsp;4.9) and 16.6 citations per year (\u0026plusmn;\u0026thinsp;22.2), Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In contrast, U.S. MD residents averaged 1.3 publications per year (\u0026plusmn;\u0026thinsp;2.4) and 3.6 citations per year (\u0026plusmn;\u0026thinsp;10.4), while Doctor of Osteopathic Medicine (DO) residents averaged 0.55 publications per year (\u0026plusmn;\u0026thinsp;1.5) and 1.1 citations per year (\u0026plusmn;\u0026thinsp;3.8). Differences between IMGs and U.S. MDs, as well as between IMGs and DOs, were significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Research quality based on h-index showed averages of 9.8 for IMGs (\u0026plusmn;\u0026thinsp;6.9), 2.2 for U.S. MDs (\u0026plusmn;\u0026thinsp;3.0) and 0.7 for DOs (\u0026plusmn;\u0026thinsp;1.9) with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 for IMGs vs U.S. MDs and IMGs vs DOs.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe major findings of this study are threefold: firstly, IMGs exhibit significantly higher research output than their U.S. MD and DO counterparts before matching into U.S. orthopaedic surgery residency programs. The quantitative findings of the present study are the most rigorous performed to date. Secondly, this trend persists through residency, with IMGs producing more research than their US-educated peers. Thirdly, the regions with the highest number of IMGs matched into orthopaedic surgery residencies are the Caribbean, Europe, and Oceania, while the states with the most matched IMGs are Massachusetts and Maryland.\u003c/p\u003e \u003cp\u003eNumber of publications, first author publications, citations, and h-index were all significantly higher for matched IMG orthopaedic surgery residents than their U.S. trained peers. Academic productivity within orthopaedics before residency was nearly ten-fold higher for IMGs than both U.S. MDs and DOs. These findings parallel those of Fares et al., who reported that matched orthopaedic IMGs averaged 26.3 publications before residency, while our study found an average of 32.8 [11]. This study expands on their analysis by including IMG publication data of IMGs during residency, assessing research quality using the h-index, and including a complete sample of matched IMGs (56 vs 44). Similar trends in research productivity among IMGs have been observed in other surgical subspecialties, such as neurosurgery[2] and plastic surgery [3]. Mignucci-Jim\u0026eacute;nez et al. demonstrated that in neurosurgery, program directors have higher expectations for IMGs to complete research prior to residency, which possibly also holds true in orthopaedics [2]. The orthoapedic journal most frequently published by IMGs before residency was the Journal of Arthroplasty, it is unclear why this is the case. As medical education increasingly emphasizes diversity, IMGs represent an invaluable resource in addressing these needs and serving the diverse American public [12]. This underscores the need for further research on strategies to enhance IMGs success in the orthopaedic residency match. Future studies could include program director responses on expectations for IMG applicants, similar to published neurosurgery studies [2].\u003c/p\u003e \u003cp\u003eWe found that the trend of increased IMG research productivity before residency continues through residency, where IMGs produce more research than their U.S. educated peers. IMGs published nearly four-fold as many publications and received nearly four times as many citations per year of residency compared to U.S. MDs and DOs. This finding supports the increased inclusion of vetted IMGs in U.S. residencies given their substantial academic productivity. Mignucci-Jim\u0026eacute;nez et al. reported a decrease IMG research productivity during residency compared to before residency [2]. This comparison was not possible to perform in the current study as we cannot calculate publications per year prior to residency without exact applicant timelines of research years and medical education. However, it appears that IMG residents maintain a comparable level of productivity despite the increased clinical burden [13]. Fares et al. reported that, on average, 4.66 years passed between completing medical school and starting residency for matched IMGs [11]. While it is evident that IMGs in orthopaedics are generally more academically productive than their peers before and during residency, it is uncertain to what degree this productivity continues post-residency. Further investigation is needed into the research productivity of IMGs during fellowship and as practicing surgeons. Additional studies could aim to determine more precise research activity timelines for IMGs before matching, including the duration of research and training prior to the U.S. match.\u003c/p\u003e \u003cp\u003eThe most common countries where matched orthopaedic IMGs completed medical school were: Grenada (17.9%), Australia (10.7%), Lebanon (8.9%) and the United Kingdom (8.9%). These results differ from Fares et al., who reported Ireland and the United Kingdom as the most common countries [11]. We found the same number of residents from European medical schools but included a total of 56 IMGs compared to their 44, explaining the difference in results. While they reported 8 residents from Central America and Caribbean medical schools, we found 23. Our results further provide guidance to applicants and a clearer picture of the origins of IMGs in orthopaedics. It is unsurprising that the Caribbean had the higher proportion of matched applicants given its proximity to and familiarity with the US medical education system [14]. Australia also had a high number of successful applicants (8.9%), but all of these applicants attended the University of Queensland Ochsner Clinical School, which completes their third and fourth year clinical rotations in the United States [15], similar to Caribbean schools thus giving these groups an advantage over other IMGs. Our findings demonstrate the geographical distribution of matched applicants in orthopaedic surgery, with the Caribbean and Europe being the regions with the most matched residents, and Massachusetts and Maryland being the states with the most matched IMGs. These results are influenced by high numbers of IMGs at Harvard Combined Orthopaedic Residency Program (HCORP) and Johns Hopkins Orthopaedic residency program. Given the success of multiple students from Queensland University\u0026rsquo;s program, future studies should evaluate the viability of a hybrid medical school curriculum outside of the Caribbean as a potential alternative for international students aiming to enter U.S. residencies.\u003c/p\u003e \u003cp\u003eOverall, this study found that IMGs have significantly higher research activity than their U.S. MD and DO counterparts before matching into U.S. orthopaedic surgery residency programs and that this trend continues through residency. Despite the distinction of successful IMG applicants in research, program directors must still carefully consider the potential for IMGs to succeed in their programs, given unique challenges they face, including visa status, work authorization, travel restrictions, and others.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are several limitations of this review. Firstly, only research publications in relation to orthopaedic surgery were included in this analysis. Research in other fields may influence matching and was not assessed. Secondly, our assessment did not include accepted abstracts, posters or podium presentations. Thirdly, despite our best efforts, there may be IMGs missing or falsely included due to errors in the public domain data used. Fourthly, we did not include several factors that have been shown to play a large role in matching into U.S. residency including: letters of recommendation, board exam scores, interview performance, and medical school academic performance. Fifthly, we did not account for distribution or variance when calculating \u003cem\u003eP\u003c/em\u003e values using unpaired t-tests. Finally, our study does not include a subgroup of foreign students who completed medical school in the United States, but are functionally similar to IMGs given their potential need for visa sponsorship.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThese findings highlight the significant differences in research output between IMGs and their U.S.-trained counterparts in orthopaedic surgery, and suggest that these differences continue throughout residency.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eFunding Declaration\u003c/b\u003e: This research received no specific grant or funding.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHuman Ethics and Consent to Participate Declaration\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJSM and FJ contributed to the study conception and design. Material preparation, data collection and analysis were performed by FJ, FA, OL and AC. The first draft of the manuscript was written by JSM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKaushal, N., R. Kaestner, and T. Rigzin, (2022) \u003cem\u003eForeign-Trained Physicians in the United States: A Descriptive Profile.\u003c/em\u003e Medical Care Research and Review, \u003cstrong\u003e79\u003c/strong\u003e(5): p. 717-730. https://doi.org/10.1177/10775587211066994\u003c/li\u003e\n\u003cli\u003eMignucci-Jim\u0026eacute;nez, G., et al., (2022) \u003cem\u003eAnalyzing international medical graduate research productivity for application to US neurosurgery residency and beyond: A survey of applicants, program directors, and institutional experience.\u003c/em\u003e Frontiers in Surgery, \u003cstrong\u003e9\u003c/strong\u003e. https://doi.org/10.3389/fsurg.2022.899649\u003c/li\u003e\n\u003cli\u003eKokosis, G., et al., (2018) \u003cem\u003eInternational Medical Graduates in the US Plastic Surgery Residency: Characteristics of Successful Applicants.\u003c/em\u003e Eplasty, \u003cstrong\u003e18\u003c/strong\u003e: p. e33. \u003c/li\u003e\n\u003cli\u003e\u003cem\u003eActive Physicians Who Are International Medical Graduates (IMGs) by Specialty, 2021\u003c/em\u003e, A.M. Association, Editor. (2021) AMA Physician Masterfile.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eACGME residents and fellows who are international medical graduates (IMGs) by specialty\u003c/em\u003e, \u003cem\u003eN.G.C.i.G.T. \u0026reg;\u003c/em\u003e, Editor. (2022) American Medical Association.\u003c/li\u003e\n\u003cli\u003eNasser, J.S., et al., (2023) \u003cem\u003eMatching into competitive surgical residencies: predictors of success.\u003c/em\u003e Med Educ Online, \u003cstrong\u003e28\u003c/strong\u003e(1): p. 2189558. https://doi.org/10.1080/10872981.2023.2189558\u003c/li\u003e\n\u003cli\u003eGauer, J.L. and J.B. Jackson, (2017) \u003cem\u003eThe association of USMLE Step 1 and Step 2 CK scores with residency match specialty and location.\u003c/em\u003e Med Educ Online, \u003cstrong\u003e22\u003c/strong\u003e(1): p. 1358579. https://doi.org/10.1080/10872981.2017.1358579 \u003c/li\u003e\n\u003cli\u003eAbbas, A.M., et al., (2024) \u003cem\u003eOrthopedic Surgery Matched Applicants Are Publishing More: A Bibliometric Analysis of Research Output.\u003c/em\u003e Cureus, \u003cstrong\u003e16\u003c/strong\u003e(3): p. e56210. https://doi.org/10.7759/cureus.56210\u003c/li\u003e\n\u003cli\u003eSchrock, J.B., et al., (2017) \u003cem\u003eA Comparison of Matched and Unmatched Orthopaedic Surgery Residency Applicants from 2006 to 2014: Data from the National Resident Matching Program.\u003c/em\u003e JBJS, \u003cstrong\u003e99\u003c/strong\u003e(1). https://doi.org/10.2106/jbjs.16.00293\u003c/li\u003e\n\u003cli\u003eVought, R., et al., (2024) \u003cem\u003eAnalysis of neurosurgery resident research activity in the United States.\u003c/em\u003e J Neurosurg, p. 1-8. https://doi.org/10.3171/2024.2.jns232752\u003c/li\u003e\n\u003cli\u003eFares, M.Y., et al., (2024) \u003cem\u003eInternational Medical Graduates in US Orthopedic Residency Programs: A Comprehensive Analysis.\u003c/em\u003e R I Med J. \u003cstrong\u003e107\u003c/strong\u003e(2): p. 40-43.\u003c/li\u003e\n\u003cli\u003eMcElvaney, O.J. and G.T. McMahon, (2024) \u003cem\u003eInternational Medical Graduates and the Physician Workforce.\u003c/em\u003e JAMA, \u003cstrong\u003e332\u003c/strong\u003e(6): p. 490-496. https://doi.org/10.1001/jama.2024.7656\u003c/li\u003e\n\u003cli\u003eBohm, K.C., et al., (2016) \u003cem\u003eOrthopedic Residency: Are Duty Hours Predictive of Performance?\u003c/em\u003e J Surg Educ, \u003cstrong\u003e73\u003c/strong\u003e(2): p. 281-5. https://doi.org/10.1016/j.jsurg.2015.09.015\u003c/li\u003e\n\u003cli\u003eDuvivier, R.J., E. Wiley, and J.R. Boulet, (2019) \u003cem\u003eSupply, distribution and characteristics of international medical graduates in family medicine in the United States: a cross-sectional study.\u003c/em\u003e BMC Fam Pract, \u003cstrong\u003e20\u003c/strong\u003e(1): p. 47. https://doi.org/10.1186/s12875-019-0933-8\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eOchsner Years 3 \u0026amp; 4\u003c/em\u003e. [cited 2024 8/10/2024]; Available from: https://medical-school.uq.edu.au/about/clinical-schools/ochsner-clinical-school/ochsner-years-3-and-4.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"IMG, international, education, training, publication, research, orthopaedic surgery","lastPublishedDoi":"10.21203/rs.3.rs-5320459/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5320459/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eInternational Medical Graduates (IMGs) have lower match rates than their United States (U.S.)-trained Doctor of Allopathic Medicine (MD) and Doctor of Osteopathic Medicine (DO) peers. This study aims to more completely elucidate the research accomplishments required for IMGs to match into orthopaedic residency and to compare their academic productivity during residency to that of U.S. MD and DO graduates.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData from orthopaedic-related journals and ACGME-accredited residency programs were extracted in July of 2024 using Python. Variables included: residency year, publications, first-author publications, citations, journals, h-index, medical school type, and the medical school and residency program locations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePrior to residency, the 56 matched IMGs had a mean of 32.8 publications, 9.8 first-author publications, and 517.1 citations. Matched U.S. MDs had an average of 3.7 publications, 1.1 first-author publications, and 61.0 citations while DO matched applicants had an average of 3.7 publications, 1.0 first-author publications, and 5.6 citations. During residency, IMG orthopaedic residents averaged 5.2 publications per year and 16.6 citations per year. U.S. MD residents averaged 1.3 publications per year and 3.6 citations per year, while DO residents averaged 0.55 publications per year and 1.1 citations per year. The h-index averaged 9.8 for IMGs, 2.2 for U.S. MDs and 0.7 for DOs. All comparisons for IMGs vs U.S. MDs and IMGs vs DOs yielded \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings highlight the significant differences in research output between IMGs and their U.S.-trained counterparts in orthopaedic surgery, and show that these differences continue throughout residency.\u003c/p\u003e","manuscriptTitle":"International Medical Graduate Orthopaedic Residents Show Higher Research Productivity Than United States Graduate Peers Before and During Residency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:48:34","doi":"10.21203/rs.3.rs-5320459/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-16T23:45:15+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-26T21:19:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-26T00:30:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-26T00:28:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Orthopaedics","date":"2024-10-23T16:12:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"49b7ee7b-42b0-4acd-8fa1-e36ed61dc0d7","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-03-01T21:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:48:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5320459","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5320459","identity":"rs-5320459","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}