Abstract
Background:
The lack of trainees from underrepresented race and gender backgrounds in orthopaedic surgery fellowship training has been well reported in the literature. The purpose of this study was to investigate the demographic trends of federally sponsored military orthopaedic surgery fellows in the Army, Navy, and Air Force. We hypothesize that there has been an increase in women selected for fellowship but that there has been no change in the race demographics of military fellows over the past 2 decades.
Methods:
A retrospective review of all available demographic data collected by the Army, Air Force, and Navy since the beginning of tracking federally funded fellowship training in orthopaedic surgery was completed (1998-2021). Data were grouped into 4-year periods for analysis to closely mirror the military assignment cycle.
Results:
Three hundred sixty-two military orthopaedic surgery fellowship board selectees were included in our analysis. The proportion of women fellows increased from 3% (n = 2/69) over 2001 to 2004 to 21% (n = 17/82) during 2017 to 2020 (p < 0.05). Fellows who identified as White comprised 82% (n = 297) of the cohort during the study period. Individuals who identified as Asian were the next highest proportion of fellows at 4% (n = 16), followed by Black (n = 14, 4%) and Hispanic (n = 13, 3%). Individuals who identified as Native Hawaiian/Pacific Islander represented 1% (n = 3), and an additional 6% (n = 20) fellows identified as “other” or “undeclared.” Over the 20-year study period, representation of Asian, Black, Native Hawaiian, and Hispanic fellows did not increase (p = 0.79, 0.81, 0.45, 0.34, respectively).
Conclusions:
Within military orthopaedics, there has been increased representation of women in fellowship training over the past 20 years. However, the proportion of fellows from underrepresented racial and ethnic groups has remained stagnant. One barrier to improving gender and race representation is the currently imprecise and inconsistent collection of demographic information. Importantly, fellowship training has a direct effect on future leadership opportunities within the military orthopaedic surgery community. A more diverse leadership may help to inspire future generations of military orthopaedic surgeons.
Level of Evidence:
IV.
Introduction
Orthopaedic surgery lags behind other specialties in the representation of individuals with underrepresented racial, ethnic, and gender identities, and this relative stagnation has been attributed to limited recruitment, retention, and promotion1–6. There continues to be widespread calls to action and plans to increase diversity in leadership through targeted and focused recruitment7–9. Investigations in race and gender representation in orthopaedic surgery intend to achieve the ultimate goal of minimizing the social determinants of health for orthopaedic patients. Patients of marginalized racial and ethnic identities experience worse surgical outcomes and higher complication rates, and increasing racial diversity among physicians improves overall quality and access to care while maintaining a high level of patient satisfaction10–14. Physician-patient gender concordance is also associated with higher patient satisfaction and better adherence to preventative care protocols15,16.
There remains a paucity of information regarding diversity within military orthopaedic surgery. A single 2018 study demonstrated a low proportion of women orthopaedic surgeons within the US Army17. Diversity and representation in military orthopaedics is not just a matter of patient care and safety, as the Department of Defense (DoD) has declared a mandate to improve the representation of individuals with marginalized racial, ethnic, and gender identities in their 2020 Military Leadership Diversity Commission Final Report18. The 2020 DoD Board on Diversity and Inclusion Report recommended “aggressive integration of diversity and inclusion” to develop an officer corps that better represents the enlisted community. As officers, military surgeons should share lived experiences and perspectives with the enlisted force that they both medically care for and lead18,19.
Fellowship programs for military surgeons also serve as a retention tool; each year of fellowship training in the military adds an additional 2 years of service commitment20. Completing a fellowship leads to promotions, leadership positions, and an extended military career21,22. Currently, all 9 of the active duty military orthopaedic surgery residency programs have both a program director and department chair who are fellowship trained.
The racial, ethnic, and gender composition of orthopaedic surgery fellows has been studied in the civilian sector, but there is a paucity of these investigations in the military medicine. The purpose of this study was to trend demographics within military orthopaedics. The primary outcome of this study is the racial, ethnic, and gender demographics of military fellows. The authors hypothesize that the representation of women in orthopaedic surgery fellowships increased throughout the 20-year study period. The authors also hypothesize that the representation of fellows of underrepresented racial and ethnic minorities has not increased during the study period.
Materials and Methods
A cross-sectional retrospective review was performed of all available fellowship board selection demographic information released by military graduate medical education departments. Fellowship data were released by the Navy from 1998 to 2020, the Army from 2000 to 2020, and the Air Force from 2013 to 2021. Fellowship applicants are selected by the Joint Service Graduate Medical Education Board for a military-funded civilian fellowship, an active duty military fellowship, or an unfunded military fellowship. All applicants selected for fellowship were included in this study. Race categorizations were not standardized throughout each service and are listed in Table I.
TABLE I.
Reported Race Categorizations for Each Service
| Army | Navy | Airforce |
|---|---|---|
| American Indian or Alaska Native Asian Black Caucasian Hispanic Other Pacific Islander |
African American American Indian or Alaska Native Asian American or Pacific Islander Caucasian Hispanic Other Undeclared |
Asian Black Caucasian Hispanic Other |
In reporting these data, the authors recognized the historical challenges with racial and ethnic categorizations. To study the embedded structural and institutional implications of historical racial and ethnic discrimination, race categories allow institutions to critically understand data related to their goals of creating a more diverse and inclusive environment3. Demographic categories were restructured into racial categories similar to those used by the DoD and US Census23,24. The race categories included in our analysis include American Indian and Alaska Native, Asian, Black and African American, Hispanic, Native Hawaiian and Pacific Islander, other, unknown/undeclared, and White. Individuals who reported as “Caucasian” were included as “White” to align with the DoD and US Census demographic strategy. In addition, Hispanic/Latino as race demographics were restructured into ethnicity groups to align with the DoD and US Census demographic strategy23,24.
Statistical Analyses
Fellowship board demographics data were divided into 5 consecutive 4-year groups to align with senior leadership turnover and military duty assignments, which are commonly 3 to 5 years. Paired Student t tests were performed to determine changes in categorical variables. A Cochran-Armitage test was completed to investigate trends in race, ethnicity, and gender within fellowships over time.
Results
A total of 362 fellows were included between the years 2001 and 2020. Gender distribution is listed in Table II. Women accounted for 12% of the total cohort over the study period. The proportion of women increased from 3% (n = 2/69) during the 2001 to 2004 period to 21% (n = 17/82) during the 2017 to 2020 period (p < 0.05) (Table II). The Cochrane-Armitage test for trends determined a significant difference in the proportion of women between periods (3% vs. 9% vs. 16% vs. 10% vs. 21%, p < 0.05).
TABLE II.
Gender Distributions of All Fellowship Trainees*
| Period | Women | Men | Grand Total |
|---|---|---|---|
| 2001-2004 | 2 (3) | 67 (97) | 69 |
| 2005-2008 | 6 (9) | 65 (91) | 71 |
| 2009-2012 | 11 (16) | 60 (85) | 71 |
| 2013-2016 | 7 (10) | 62 (90) | 69 |
| 2017-2020 | 17 (21) | 65 (79) | 82 |
| Total | 43 (12) | 319 (88) | 362 |
| 2020 active duty personnel (%) | 19 | 81 | — |
Demonstrated by number (% of fellows during specific period).
Race and ethnicity grouped distributions throughout the study period are listed in Table III. Fellows who identified as White consisted of 82% (n = 297) of the study cohort. Individuals who identified as Black or African American comprised only 4% (n = 14) of fellows during the 20-year period. Individuals who identified as Asian represented 4% (n = 16) of fellows. Service members who identify as Native Hawaiian/Pacific Islander represent 1% of the active duty population and 1% (n = 3) of fellows selected. Individuals who identified as “other” or “undeclared” represented 6% (n = 20) of the military fellowship selectees.
TABLE III.
Race Distribution Among All Fellowship Trainees*
| Period | American Indian or Alaska Native | Asian | Native Hawaiian or Pacific Islander | Black | Other | Undeclared | White | Grand Total |
|---|---|---|---|---|---|---|---|---|
| 2001-2004 | 0 (0) | 2 (3) | 0 (0) | 3 (4) | 1 (2) | 4 (6) | 58 (84) | 69 |
| 2005-2008 | 0 (0) | 2 (3) | 2 (3) | 4 (6) | 2 (3) | 2 (3) | 57 (80) | 71 |
| 2009-2012 | 0 (0) | 8 (11) | 1 (1) | 1 (1) | 3 (4) | 3 (4) | 53 (75) | 71 |
| 2013-2016 | 0 (0) | 2 (3) | 0 (0) | 2 (3) | 3 (4) | 1 (2) | 57 (83) | 69 |
| 2017-2020 | 0 (0) | 2 (2) | 0 (0) | 4 (5) | 1 (1) | 0 (0) | 72 (88) | 82 |
| Total | 0 (0) | 16 (4) | 3 (1) | 14 (4) | 10 (3) | 10 (3) | 297 (82) | 362 |
| 2020 active duty personnel | 1% | 5% | 1% | 17% | 4% | — | 70% | — |
Demonstrated by number (% of fellows during specific period). Active Duty Personnel are self-reported demographics from 2020. Undeclared and multiracial were not consistently reported.
Fellows who were identified as Black or African American demonstrated no significant growth with an average of 0.7 fellows per year, and a Cochrane-Armitage test for trends demonstrated no significant differences in proportion between periods (p = 0.81). Fellows identified as Asian demonstrated no significant difference in proportion of fellows between periods (p = 0.80). Fellows identified as Black, Asian, and Native Hawaiian/Pacific Islander demonstrated no significant difference in proportion of fellows between periods (p = 0.81, p = 0.80, and p = 0.45, respectively). Women who were identified as being non-White (Asian, Pacific Islander, Hispanic, Black, or African American) represent 2% of all fellows.
Individuals who identify as having a Hispanic or Latino ethnicity comprised 17% of the US military active duty population18 but represent only 3% of all military orthopaedic fellows during the 20-year study period. The Cochrane-Armitage test for trends demonstrated that there was no difference in the proportion of Hispanic/Latino fellows trained between periods (p = 0.34) (Table IV). No fellow in any service was identified as American Indian or Alaska Native.
TABLE IV.
Ethnicity Distribution Among All Fellowship Trainees*
| Period | Hispanic or Latino | Non-Hispanic or Latino | Grand Total |
|---|---|---|---|
| 2001-2004 | 1 (2) | 68 (98) | 69 |
| 2005-2008 | 2 (3) | 69 (97) | 71 |
| 2009-2012 | 2 (3) | 29 (97) | 71 |
| 2013-2016 | 4 (6) | 65 (94) | 69 |
| 2017-2020 | 3 (4) | 79 (96) | 82 |
| Total | 12 (3) | 350 (97) | 362 |
Demonstrated by number (% of fellows during specific period).
Discussion
To the best of our knowledge, this is the first study to assess the demographic trends in fellowship selection among military orthopaedic surgeons. Our results demonstrate that the proportion of women selected for fellowship training by the military continues to increase, while individuals of underrepresented racial and ethnic identities represent a lower proportion of fellows without significant change. White fellows comprised 82% of those selected, with the trend largely unchanged over 2 decades and substantially behind their civilian counterparts25.
Racial and ethnic diversity within Accreditation Council for Graduate Medical Education-accredited orthopaedic fellowship programs has previously been investigated through self-identification over 2006 to 2015. In that study, fellow race distribution was 69% White, 17% Asian, 4% Black, and less than 1% Native Hawaiian/Pacific Islander and American Indian/Alaska Native fellows. Five percent of fellows identified with a Hispanic ethnicity25. In our present investigation, the racial distribution of military fellows were similar to civilian fellows and remained consistent throughout the study period.
Over the study period, the number of women selected for fellowship training increased by 18%, a similar trend to that seen in the 2018 study by Poon et al.25 Of all civilian orthopaedic surgery residents, the proportion of women fellowship applicants has ranged from 7% to 10% annually, and the percentage of matched applicants ranged from 8% to 12%26,27. The racial and ethnic analysis of the women selected reveals that 69% of those selected were White, 10% were Asian, 7% were Hispanic, 3% were Black, and 3% were Native Hawaiian (Fig. 1). Thus, it is important to describe this increase in women selected for fellowship predominantly as an increase in White women selected for fellowship.
Fig. 1.
Racial and ethnic analysis of the women selected for fellowship during the study period.
Fellowship programs can only select applicants from residency programs. In 2019, Poon et al. demonstrated that female representation in orthopaedic residency programs increased at a rate significantly lower than other specialties to include general surgery, neurosurgery, and urology. Representation of residents of White and Hispanic origin increased and decreased for Native Hawaiian/Pacific Islander residents and did not change for African American or Asian American representation28. An additional investigation of orthopaedic surgery residency applicants demonstrated that minority race, not gender, was associated with lower odds of admissions into orthopaedic surgery residency, despite accounting for academic performance metrics29. A cross-sectional study of ACGME program-reported censuses from 2001 to 2018 demonstrated that the risk of unintended attrition was higher among female residents (Relative Risk [RR]: 1.17) when compared with male counterparts and underrepresented minorities in medicine (URiM) (RR: 1.92) when compared with non-URiM residents30. Our findings should be interpreted with the consideration that the racial diversity within orthopaedic residency programs has remained stagnant and that these fellows represent residents who were also competitive enough to apply and be selected for residency and fellowship.
Fellowships in the Military
Although some subspecialties in military orthopaedics have better representation than others, there is a contrast with orthopaedic fellows trained in DOD military institutions (Table V). These programs exclusively train Army surgeons, almost all Army hand and sports surgeons are trained in these programs, and each program typically trains 2 fellows a year. Over the past 2 decades, the underrepresented minorities who trained at these fellowships were rare. Recruiting, developing, and mentoring underrepresented minority residents to pursue military fellowships may lead to retention of a diverse workforce and leadership opportunities that influence organization culture. In multiple studies, having these individuals in leadership is recognized as a central driver to influencing others with shared identities to pursue that same specialty because they can see themselves in that role31–35(p5).
TABLE V.
Total Fellows By Race and Gender Within Active Duty Military Fellowship Programs
| Race/Fellowship | Female | Male | Grand Total |
|---|---|---|---|
| American Indian/Alaska Native | — | — | — |
| Hand | — | — | — |
| Sports | — | — | — |
| Asian | 1 | 3 | 4 |
| Hand | 1 | 2 | 3 |
| Sports | — | 1 | 1 |
| Black | — | 1 | 1 |
| Hand | — | — | — |
| Sports | — | 1 | 1 |
| Latino or Hispanic Ethnicity | 2 | 1 | 3 |
| Hand | 1 | — | 1 |
| Sports | 1 | 1 | 2 |
| Native Hawaiian/Pacific Islander | — | — | — |
| Hand | — | — | — |
| Sports | — | — | — |
| Other | 1 | 3 | 4 |
| Hand | 1 | 1 | 2 |
| Sports | — | 2 | 2 |
| White | 8 | 51 | 59 |
| Hand | 5 | 25 | 30 |
| Sports | 3 | 26 | 29 |
| Grand Total | 12 | 59 | 71 |
Solutions
There have been several studies that discuss tools for improving racial diversity within a physician workforce6,28,36,37. When surveyed about barriers to increasing diversity, 69% of programs stated that their most common barrier to increasing diversity was secondary to a “lack of faculty, deterring applicants from applying”38. Within this same survey, over 50% of programs stated that the minority applicants are ranked highly but seem to fail to match and feel as if there are not enough underrepresented minority applicants are applying to their program.
In our specific population, we suggest focusing on recruitment and retention of a diverse workforce. Not only it is important for a training program to recruit and matriculate fellows of underrepresented racial, ethnic, and gender identities but also it is essential that those fellows feel welcomed and valued in their workplace. If fellows feel like their skills and lived experience are respected within military orthopaedics, we believe this will create an environment for trainees to develop long careers and reach positions of leadership and influence within the workforce.
As representation of residents with marginalized racial identities increases, internal efforts can further support the pipeline of quality trainees. The military can start by making an intentional effort to connect residents with mentors, increasing exposure and opportunities within and outside the military. The Society of Military Orthopaedic Surgeons E. Anthony Rankin Scholarship Program has allowed for underrepresented students to gain exposure military orthopaedics and develop mentorships with residents and surgeons with the intent to improve the diversity within the field. Previous studies indicate that it will take hundreds of years for civilian orthopaedics to reach equitable gender representation31. However, because the military turns over at a far more rapid pace, they are in a position to promote fellows into positions of leadership at an accelerated pace. If more residents of underrepresented minorities are selected for fellowships, they can also become organizational leaders and champions of military orthopaedic culture.
Educational curriculum on racism, sexism, and implicit bias has been introduced with significant success in other surgical training programs39–41. A shared educational workload between individuals of underrepresented and overrepresented race, ethnic, and gender identities may alleviate the equity work burden6. In addition, program leadership may benefit from training on equity and implicit bias throughout their careers to become better serve those they care for and represent40,42–44.
The variables we used to measure diversity in military orthopaedics are race, ethnicity, and gender. However, each branch used different race categories, and none distinguished race from ethnicity. These inconsistencies make establishing a baseline population challenging. To that end, more effective categories with definitions should be established and standardized. The military may consider using the recently updated American Medical Association Guidelines, which are explicit for how they recommend this information be presented, and thus may serve also as a model for how it should be collected45. The same is true for identifiers such as sex, gender expression, gender identity, and sex assigned at birth. The military should determine which of these identifiers are most important for future demographic and equity research and use appropriate labels for chosen categories. Critically, the intersectionality of racial, ethnic, and gender identities should be considered because an improvement of military orthopaedic diversity is a complex shift of identity representation within our physician population which should strive to reflect that of our patients46. As an example, one could argue that diversity has increased among military fellows by simply looking at the percentage of women, but on further scrutiny, this is not true for all women. Increased proportions of both women and Black residents do not necessarily reflect an increase in Black women residents, thus underscoring the importance of being specific in both how we collect, label, and analyze future data.
Limitations
Our investigation has several limitations. Several of the fellows' races were listed as “other” or “undeclared” which limits a more complete demographic analysis. This label may describe individuals who do not feel comfortable identifying their race, and it may describe individuals with 2 or more races. Over 10% of the US population identified as having 2 or more races, and we believe that these individuals are not accurately described in our military orthopaedic data47. All Asian American and Pacific Islander identities were combined into a single label in Navy data. To create a standardized racial grouping framework, all individuals in this category were labeled as “Asian”. The authors understand that this initial label encompasses many identities, and the authors acknowledge the possible erasure of identities caused by this relabeling. The military orthopaedics data listed Hispanic as a race identifier, and this group was compared with the ethnicity group “Hispanic or Latino” in the DoD and US Census data23,24. In addition, we were only able to report those who were successfully selected by the Joint Graduate Medical Education Selection Board for each representative year. The race and gender demographics of applicants for each year are not reported in this investigation; henceforth, we were unable to determine match rates for fellowship.
A demographic descriptor labeled “gender” was obtained from the available military orthopaedic data set; individuals labeled “Male” or “M” were relabeled as “men”, and individuals labeled “Female or ‘F’ were relabeled “women.” We acknowledge the inaccuracy of claiming equivalency of a gender identity with a binary of sex labels assigned at birth, but for the purposes of this study, we found this was the most accurate way to compare our population with other populations within current literature which are described within a gender binary of “men” and “women.” Some individuals may have been misgendered in this relabeling.
Conclusion
Within military orthopaedics, there has been increased representation of women in fellowship training over the past 20 years. However, representation of marginalized racial and ethnic groups has remained stagnant. Further consideration should be given to the sustained efforts of recruiting underrepresented minorities as well as creating a culture of equity and inclusion within military orthopaedics.
Sources of Funding
No funding source placed a role in this investigation.
Footnotes
Investigation performed at the Uniformed Services University of the Health Sciences, Bethesda, MD
The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions, or policies of Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial. products, or organizations does not imply endorsement by the US Government.
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A560).
Contributor Information
Morgan Askew, Email: morganaskew.mil@gmail.com.
Michael Baird, Email: mdb280@gmail.com.
Sevil Ozdemir, Email: ozdemir5@msu.edu.
Shaun Williams, Email: shaun.r.williams88@gmail.com.
Valentina Ramirez, Email: VARA1515@gmail.com.
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