Comparing match outcomes of international medical graduates (IMGs), U.S. allopathic (MDs), and osteopathic graduates (DOs) into orthopaedic spine surgery fellowship programs from 2019-2024.

Background: International medical graduates (IMGs) play a vital role in the U.S. healthcare system, particularly in addressing workforce shortages and serving underserved populations. Despite their substantial contributions, IMGs remain underrepresented in surgical subspecialties, including orthopaedic surgery, where they comprise a small proportion of the workforce. Spine surgery is a highly competitive orthopaedic subspecialty with limited growth in fellowship positions and low match rates. While trends in IMG representation have been described in residency training, data on IMG match outcomes in orthopaedic subspecialty fellowships, particularly spine surgery, remain limited. The aim of this study was to evaluate U.S. orthopaedic spine fellowship match outcomes among IMGs and to compare these outcomes with those of U.S. allopathic (MD) and osteopathic (DO) graduates. Methods: We conducted a retrospective analysis of applicants to U.S. orthopaedic spine surgery fellowship programs using San Francisco Match (SF Match) data from 2019 to 2024. This study period was selected because these years contained the most complete and consistently collected applicant-level data for the variables of interest. Applicants included MD, DO, and IMGs. Variables analyzed included United States Medical Licensing Examination (USMLE) step 1 and step 2 scores, number of applications submitted, interview invitation rates, number of contiguous ranks, applicant and program rank positions, and match outcomes. Descriptive statistics, analysis of variance, and linear regression were used to assess differences among groups, with statistical significance defined as P<0.05. Results: A total of 1,054 applicants were included (674 MD, 72 DO, 308 IMG). IMG applicants originated from 45 countries/regions, most commonly India, Egypt, Jordan, and Canada. Compared with MD and DO applicants, IMGs had significantly lower USMLE step 1 and step 2 scores, lower interview invitation rates, and fewer contiguous ranks (P<0.0001 for all). IMGs submitted more applications on average but had markedly lower interview yield (9%) compared with MD (50%) and DO (29%) applicants. Among IMGs, matched applicants demonstrated significantly higher USMLE scores, interview rates, and rank list lengths than unmatched applicants (P<0.01 for all). Additionally, applicant rank outcomes differed significantly among groups (P<0.01); 10% of IMGs matched at their first-choice program compared with 15% of MD applicants and 6% of DO applicants. Conclusions: IMG applicants to orthopaedic spine surgery fellowships demonstrate differences from MD and DO applicants across multiple domains of the application process, including standardized test performance, interview invitation rates, and match outcomes. Even among those who successfully match, IMGs were more likely to be ranked lower by the programs where they ultimately matched. These findings provide important benchmark data on orthopaedic spine fellowship match outcomes and may help inform future studies evaluating factors associated with fellowship selection and match success.