Gender and Osteopathic Representation in U.S. General Surgery Residency, 2024-2025: Divergent Patterns Across Postgraduate Training.

Introduction Women and osteopathic (DO) physicians remain underrepresented in the field of general surgery, from residency training to the practicing workforce. Efforts to improve diversity in general surgery residency have focused on gaps in gender and osteopathic representation; however, it remains unclear whether these patterns change consistently across postgraduate years (PGY). This study tested the hypothesis that gender and osteopathic representation follow distinct patterns across training by evaluating resident-level differences in gender representation across PGY levels and degree type, and by examining program-level associations among female representation, osteopathic representation, and historical American Osteopathic Association (AOA) affiliation in U.S. general surgery residency programs. Methods This retrospective cross-sectional study analyzed publicly available resident rosters from Accreditation Council for Graduate Medical Education-accredited U.S. general surgery residency programs during the 2024-25 academic year. Program websites, identified through the Fellowship and Residency Electronic Interactive Database Access, were used as the source of detailed resident rosters. Resident-level variables included postgraduate year (PGY1-5), sex, and medical degree type (MD vs. DO). Programs lacking sufficient publicly available resident-level data were excluded. Female and DO representation were compared across PGY levels using chi-square analyses and logistic regression. Program-level analyses classified programs according to whether they met or exceeded national benchmarks for female representation (49.9%) and DO representation (15.1%), based on 2024-25 national percentages of active general surgery residents. Associations between program-level female and DO representation were assessed using chi-square testing and logistic regression. Results Among 364 accredited programs, 292 met the inclusion criteria, representing 7,843 residents after exclusion of 319 residents with incomplete profiles. Female representation declined across training levels, from PGY1 (53.1%) to PGY5 (47.1%), with significant differences across cohorts. Increasing PGY level was associated with lower odds of being female (odds ratio (OR) = 0.93 per PGY increase, 95% CI: 0.90-0.96, p < 0.001). In contrast, DO representation remained relatively stable across PGY levels. Stratified analyses demonstrated similar female proportions among MD and DO residents, without significant interaction between degree type and PGY level. At the program level, programs with above-national DO representation were not more likely to also demonstrate above-national female representation (OR = 0.66, 95% CI: 0.41-1.08, p = 0.098). Likewise, historically AOA-affiliated programs were not more likely than non-AOA programs to meet or exceed the national benchmark for female representation. Conclusions In a large, national sample of general surgery residents, female representation decreased across PGY levels while DO representation remained stable. Osteopathic and gender representation were not significantly associated at the resident or program level, suggesting these dimensions of representation may be shaped by distinct mechanisms within surgical training. Efforts to improve equity in general surgery may therefore require targeted strategies addressing both osteopathic inclusion and the training-environment factors that may influence gender representation across residency.