CORR Insights®: Do Women and Minority Orthopaedic Residents Report Experiencing Worse Well-being and More Mistreatment Than Their Peers?

Where Are We Now?

Orthopaedic surgery is the least-diverse specialty among all medical and surgical specialties, with only 18% of orthopaedic surgery residents being women and 5.9% of practicing orthopaedic surgeons being women [2, 9, 13]. By contrast, 49% of entering medical students are women [4]. Residents who leave orthopaedic surgery programs are more likely to be women [3], and women residents overall are more likely to feel overwhelmed and be mistaken for staff at lower training levels [1]. Residents from racial and ethnic minority groups are almost at twice the risk of leaving a surgical residency, and women residents have 1.16 times the risk of attrition from surgical residency compared with their nonminority and men counterparts [8]. Orthopaedic surgery, in particular, has the highest attrition rates of Black residents [10]. Although attrition historically has included both voluntary leave and termination, a previous report suggested that the treatment of residents from racial and ethnic minority groups leads to withdrawal under duress from an uneven playing field, with residents from racial and ethnic minority groups and those who are White men being held to different standards [10], contributing to a perception that training programs in White-majority, high-earning specialties such a orthopaedics are structured, even unintentionally, in a way to maintain the majority status of White men by creating an environment of hostility rather than actively excluding women and residents from racial and ethnic minority groups. For example, an American Academy of Orthopaedic Surgeons national survey found that women orthopaedic surgeons were more likely to experience discrimination, bullying, and sexual harassment in professional working environments [14].

To this end, Gerull et al. [7] surveyed residents in orthopaedic surgery programs to evaluate whether the well-being of women and residents from racial and ethnic minority groups differed from that of their peers and whether women and minority residents experience more mistreatment. They found that women experienced more mistreatment, gender discrimination, and emotional exhaustion than their counterparts who were men. Women residents reported more thoughts of leaving than men did. Furthermore, residents from racial and ethnic minority groups reported more mistreatment and racial discrimination than their nonminority counterparts. Although these findings are consistent with prior reports on racial and gender diversity [8, 12], they provide further evidence of the differing training experiences between cohorts of orthopaedic residents, depending on their gender and race.

Based on these discoveries, training programs should identify the source of mistreatment and discrimination, whether from within the program or greater hospital system. Additionally, programs should offer support and mentoring for female residents and residents from ethnic and racial minority groups to protect against emotional exhaustion and thoughts of leaving.

Where Do We Need To Go?

In addition to being the least-diverse medical specialty, orthopaedic surgery is one of the most competitive specialties to match into, with only a 63% match rate in 2023 [11]. Additionally, choosing to match into such a competitive specialty as a woman or an individual from a racial or ethnic minority group, while having to overcome the perception that women or minorities are not welcome, requires another layer of resilience. Therefore, when women and minorities match into orthopaedics and then report discrimination, harassment, and burnout, as reported by Gerull et al. [7], the next question should not be what is wrong with these women and residents from racial and ethnic minority groups that they cannot handle or cope with the rigors of orthopaedic residency. Rather, we should ask: What is wrong with the cultures within orthopaedics, and why can’t the field evolve to accommodate diversity and treat all residents with the respect and fair training environment they deserve? Furthermore, by failing to support the training environments of all residents, orthopaedics may appear unappealing to the large percentage of talented and intelligent women medical students who now occupy entering classes at medical schools but are choosing to pursue other specialties.

How Do We Get There?

It is now clear from Gerull et al. [7] and prior reports [14, 15] that women and minorities have worse experiences in orthopaedics residency than their men and White counterparts, so what can we do about it? First, the mistreatment of residents ultimately falls on residency leadership. It is sadly unrealistic to expect that all attendings will treat residents with respect and always foster an environment of equality. However, it is then incumbent upon residency leadership to hear the concerns of residents, foster a culture where a baseline level of respect is the expectation, and protect residents against mistreatment. To do so, we must move away from anonymity. Residency programs should have an open forum, such as town halls, small groups, or assigned mentors, to create safe spaces for harassment and mistreatment to be discussed openly without fear of retaliation. This also includes the ability to evaluate attendings honestly, just as residents are evaluated by attendings. Attendings or faculty who continue to perpetrate abuse should simply not have the privilege of working with residents. Although the hierarchical nature of surgical training is unlikely to change, nor should it necessarily change given the educational value of graduated responsibility, the power dynamics that the hierarchy creates can often provide fuel for abuse. Therefore, residency leadership should recognize and acknowledge that the power dynamics and structural inequality in residency training may lead to underreporting of harassment, and leadership should actively seek out this feedback.

Additionally, women residents and those from racial/ethnic minority groups should receive increased mentorship throughout residency. Rather than asking them to conform to the hierarchy of surgical training that was created before women and people from racial minority groups were allowed into medical schools, perhaps residency should offer some flexibility to address the fact that the training needs of these populations are different from those of men and White people orthopaedic population. As such, mentorship both on an individual and group basis is important, such as department-sponsored women’s groups where women faculty can meet with women residents routinely to foster community. However, although mentorship of residents could come from faculty of the same gender, ethnicity, or race, given the lack of diversity within orthopedics, it is unrealistic to expect that residents will receive a matched mentor in these strict terms. Therefore, program leadership should make every effort to include men and White people in the mentorship process to empower not only the residents, but also the faculty alike in being catalysts for change within orthopaedics. Ultimately, the most important aspect is that women and residents from racial and ethnic minorities feel supported by their own department, faculty, and peers in their journey through orthopeadic training, regardless of where that support necessarily comes from. Similarly, community among faculty and residents from racial and ethnic minority groups should be encouraged and supported by the department. If the department lacks minority and women faculty members, a goal of the department should be to expand its recruitment, and the department should then cast a wider net to the greater surgical community at the institution to pair women and residents from racial and ethnic minority groups with appropriately matched mentors, even if not in orthopaedics specifically.

Diversity in orthopaedics is progressing and certainly in a better state than 10 to 20 years ago, but we have a long way to go. Although recruitment of medical students is one important step, if we attract the brightest women and minority students to orthopaedics only to harass and undermine their success during the residency training process, then we really haven’t improved anything.

Read This Next

• This book chronicles the misogyny experienced by Frances Conley MD, who went through neurosurgery residency and became the first woman in a surgical department at her university [6].

• Another book is an anthropologic study of 33 women surgeons; in it, the author describes the differences in the experiences of women and men surgeons [5].