Pipelining patterns in the shoulder and elbow surgery fellowship match: An analysis from 2018 to 2024.

Introduction: Pipelining is defined as the concentration of positions filled by graduates from the same or overlapping training programs. For fellowships, a history of high-quality fellows from a particular residency program may foster confidence and a preference for matching additional candidates from that program. Similarly, applicants may favorably rank programs at which previous co-residents or faculty mentors have had positive experiences. In light of the growing interest in promoting diversity and inclusion in the application process, this study evaluates the prevalence of pipelining and residency program representation within shoulder and elbow surgery fellowships. The purpose of this study is to quantify pipelining trends in shoulder and elbow fellowship matches between 2018 and 2024. Methods: We analyzed match data from the San Francisco Match from 2018 to 2024, encompassing allopathic (MD), osteopathic (DO), and international medical graduates (IMGs), and excluded programs with less than 5 years of match data. Pipelining ratios (PRs) were calculated using the formula: PR = 1 - (number of unique residency programs matched / total number of fellowship positions available) and compared among programs and US regions. A PR of 1 indicates 100% pipelining, while a PR of 0 signifies no pipelining. The representation ratio (RR) was calculated and defined as the number of residents from a particular residency who matched into a specific fellowship divided by the total number of matched residents from the respective residency. Results: A total of 250 matched applicants (210 MD, 20 DO, and 20 IMG), originating from 142 unique residency programs were evaluated across 26 fellowship programs. The most highly represented allopathic residencies included Thomas Jefferson (n = 9; 3.6%), University of Rochester (n = 6; 2.4%), and St Louis University School of Medicine (n = 5; 2.0%). The mean PR across all fellowships was 0.06 ± 0.08 (p = 0.0006), ranging from 0 (n = 15) to 0.32 (n = 1). The highest PR values were observed for Thomas Jefferson (0.32), Washington University (0.21), University of Florida (0.17), and Florida Orthopedic Institute (0.15). The highest RR values were observed for Baylor residents matching at University of Washington (0.50), Thomas Jefferson residents matching at Thomas Jefferson (0.44), and University of Rochester residents matching at Union Memorial (0.33). Overall, nearly 58% of the fellowship programs demonstrated no evidence of pipleining and the remaining 42% exhibited either minimal to relatively higher levels of pipelining. Conclusion: There is wide variability in the rate of pipelining in shoulder and elbow surgery fellowships. Despite study limitations, including the relatively short observation period and absence of granular data on applicant/program rank order and reasons for rank decisions, this data contributes to greater transparency in the fellowship match. Recognizing these trends may help applicants make more informed decisions and better direct their application efforts during the fellowship match. Level of evidence: IV.