Gender influence on career trajectory as a shoulder and elbow surgeon

Abstract

Background

Women continue to make up a minority of orthopedic surgeons, especially shoulder and elbow surgeons. There exists no study that investigates the effect of gender on one's academic career as a shoulder and elbow orthopedic surgeon, which was the purpose of this cross-sectional study.

Methods

The American Shoulder and Elbow Surgeons website was used to identify surgeons. Demographics, education, and current professional roles were obtained using the websites of institutions, hospital employers, physicians, LinkedIn, and Doximity. Research productivity metrics were obtained using SCOPUS and Google Scholar. Outcome measures included current academic/leadership roles, and research productivity. Statistical analysis was performed using the Chi-squared test and Mann–Whitney U test.

Results

Totally, 893 surgeons were identified, 60 being female (6.7%). Males had a significantly higher average h-index (P = 0.003), total number of publications (P = 0.019), citations (P = 0.03) and ASES membership ranks than female surgeons (P = 0.037; P = 0.004). There were no significant differences between genders in current professional or leadership roles.

Discussion

Female surgeons had a significantly lower number of citations, publications, and h-index but equal leadership positions such as fellowship director, residency director, chief of service, and department chair compared to their male counterparts.

Level of evidence

Level III, cross-sectional study.

Introduction

Despite making up more than half of all medical students and 37.1% of all practicing physicians, women make up just 5.9% of practicing orthopedic surgeons, the lowest of any specialty.^1,2 While a concerted effort has been made to eliminate this disparity, still only 18.3% of orthopedic residents are female in contrast to 47.3% of all resident physicians being women. ¹ Fortunately, as a result of the active recruitment of female medical students by residency programs, the current proportion of female orthopedic surgeons has increased at a rate of 2% each year. ³

The gender differences seen in the demographics of orthopedic surgery are heightened in certain subspecialties, specifically shoulder and elbow surgery.^4–6 Studies show that women make up only 5.4% of practicing shoulder and elbow surgeons, which is less than other orthopedic subspecialties.^4,7,8 In addition, disparities exist in terms of orthopedic academic productivity. An analysis of orthopedic publications from 1987 to 2017 found that women made up only 1.7% of senior authors and 4.4% of first authors. ⁹ Furthermore, a recent study of spine surgeons found that women hold academic positions of lower rank, produce fewer publications, have fewer senior author and high-impact senior author positions, and maintain a lower h-index than their male counterparts. ¹⁰

The impact of gender on research output is also reflected in the proportion of women holding leadership positions. Previous studies have found that women make up just 4.1% of shoulder and elbow fellowship faculty and only 3.3% of shoulder and elbow fellowship directors.^4,11 As shoulder and elbow surgery, and more over orthopedics in general, is a historically male-dominated field, it is important to evaluate whether an increase in number of female orthopedic surgeons will overcome the inherent barriers that accompany underrepresented groups in the field of medicine.

With low rates of women in the field of Shoulder and Elbow Surgery, it is important to understand the impact of gender on one's career trajectory in this subspecialty. The purpose of this investigation was to evaluate whether female shoulder and elbow surgeons would have similar academic rank, leadership positions, and academic productivity compared to their male counterparts.

Methods

Study cohort

From March 2023 to July 2023, orthopedic shoulder and elbow fellowship-trained surgeons were identified using the directory listed on the American Shoulder and Elbow Surgeons (ASES) website. ¹² Non-physicians, physicians no longer practicing medicine, physicians completing residency or fellowship training, and physicians practicing outside of the United States of America were excluded from final analysis. Regarding ASES membership status, corresponding members, fellow members, and affiliate members were also excluded. Of 1377 members listed in the ASES database, 893 met inclusion criteria and were included in the analysis.

Surgeon evaluation and data collection

Demographic information for each surgeon was gathered using websites of academic institutions, hospital employers, personal physician websites, and LinkedIn. Demographic information for each surgeon including sex, race (defined as White and non-White), medical school attended, residency program completed, and fellowship program completed was recorded. Medical school, residency, and fellowship institutions and years attended, additional education, academic rank, and current professional roles were also obtained. Surgeons who attended medical schools that were not accredited in the United States were defined as International Medical Graduates (IMG), while those who attended medical schools that were accredited in the United States were defined based on whether they attended allopathic (MD) or osteopathic (DO) medical schools. Academic rank (instructor/lecturer, assistant professor, associate professor, and full professor), as well as professional roles and leadership positions (chief of service, residency program director, fellowship program director, and department chair), were also collected.

Research productivity

Research productivity was evaluated using number of publications, number of citations, and h-index, which was obtained using Google Scholar and SCOPUS. The h-index is defined as the “highest number ‘h’ such that the individual has published ‘h’ papers that have each been cited at least ‘h’ times”. ¹³ The h-index serves to balance both the quantity and quality of a researcher's output by examining the number of publications and the impact of each publication. One important concession of these research indices is that because it is predicated on impact of an author's publication over time, early-stage researchers are at a disadvantage as their publications have not had enough time to be cited. ¹³

Journal editorial board positions were extracted from the following shoulder and elbow journals based on impact factor and evaluations by Scimago's Science Journal Rankings (SJR) ¹⁴ (Table 1) (Arthroscopy, Journal of Shoulder and Elbow Surgery, Clinical Orthopaedics and Related Research, Journal of American Academy of Orthopaedic Surgeons, The Orthopaedic Journal of Sports Medicine, Seminars in Arthroplasty: JSES, Journal of Shoulder and Elbow Arthroplasty, Journal of Bone and Joint Surgery, American Journal of Sports Medicine, Journal of Shoulder and Elbow Surgery International, Journal of Shoulder and Elbow Surgery: Reviews, Reports, and Techniques, Shoulder and Elbow, British Journal of Sports Medicine, The Bone and Joint Journal, Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA), and International Orthopaedics).

Table 1.

Demographics among American shoulder and elbow surgeons.

	Male (n = 833)	Female (n = 60)	P-Value
Race			P = 0.753
White	153 (18.4%)	12 (20.0%)
Non-White	680 (81.6%)	48 (80.0%)
ASES Membership			P = 0.037*
Candidate	305 (36.6%)	29 (48.4%)
Associate	226 (27.1%)	20 (33.3%)
Active	278 (33.4%)	11 (18.3%)
Senior	24 (2.9%)	0 (0.0%)
Region			P = 0.423
South	284 (34.1%)	20 (33.3%)
West	170 (20.4%)	12 (20.0%)
Northeast	185 (22.2%)	19 (31.7%)
Midwest	190 (22.8%)	9 (15.0%)
Rico	4 (0.5%)	0 (0.0%)
Medical Degree			P = 0.431
MD (U.S.)	741 (89.0%)	55 (91.7%)
DO (U.S.)	35 (4.2%)	2 (3.3%)
MD (IMG)	57 (6.8%)	3 (5.0%)
Additional Degree			P = 0.375
Yes	118 (14.2%)	11 (18.3%)
No	715 (85.8%)	49 (81.7%)

^*P < 0.05, statistically significant.

Statistical analysis

The following variables were compared statistically between male and female fellowship-trained shoulder and elbow surgeons: demographic characteristics, academic rank, academic leadership, journal editorial board positions, h-index, number of citations, and number of publications. The Chi-squared test was used for categorical variables while Fisher's exact test was employed for categorical sample sizes where the Chi-squared test was not appropriate. For continuous variables that passed equal variance testing, an unpaired T-test was employed based on the central limit theorem. For instances where continuous variables did not demonstrate equal variance, non-parametric testing such as the Mann–Whitney U test was used. Academic rank and ASES membership status was analyzed between female and male surgeons first using the Chi-squared test for association followed by analysis of directionality in those holding an academic title or ASES membership using a one-tailed Mann–Whitney U test. Statistical analysis was conducted using SPSS Student Statistics version 28.0 (IBM, Armonk, New York) with statistical significance set at P < 0.05. Power analysis was performed using G*Power (Version 3.1.9, Berlin, Germany) which determined statistical analyses were sufficiently powered for the desired effect size of 0.3.

Results

Cohort demographics

Of the 1377 members identified in the ASES database, a total of 893 (females = 60, males = 833) orthopedic shoulder and elbow surgeons met inclusion criteria. There were no significant differences between the cohorts with respect to race, geographic region of practice, type of medical degree (MD vs. DO), international medical graduate (IMG) status, or attainment of additional graduate degrees beyond the primary medical degree (Table 1).

ASES membership

Analysis of the ASES database membership rank (candidate, associate, active, senior) between men and women found that membership status is significantly associated with gender, meaning the distribution of membership status differs between males and females (P = 0.037 (Chi-squared)). Women were more likely to hold lower ASES membership ranks while men were more likely to hold higher ranks (P = 0.004 (Mann–Whitney U test)) (Table 1).

Academic rank and leadership

There were no significant differences in fellowship directorship between male and female shoulder and elbow surgeons (6.8% vs. 1.7%, P = 0.116), as well as serving as residency directors (P = 0.189), department chairs (P = 0.468), or chiefs of service (P = 0.208). Men and women were no more likely to hold academic rank (P = 0.305) (Chi-squared) or a higher vs. lower academic rank (P = 0.278) (one-tailed Mann–Whitney U test). Additionally, there was no difference between males and females when analyzing positions on a journal editorial board (P = 0.771) (Table 2).

Table 2.

Leadership positions.

	Male (n = 833)	Female (n = 60)	P-Value
Academic Rank			P = 0.305 P = 0.278 †
Instructor/Lecturer	21 (2.5%)	1 (1.7%)
Assistant Professor	117 (14.0%)	10 (16.7%)
Professor	108 (13.0%)	11 (18.3%)
Full Professor	113 (13.6%)	3 (5.0%)
No Title	474 (56.9%)	35 (58.3%)
Residency Director			P = 0.189
Yes	19 (2.3%)	3 (5.0%)
No	814 (97.7%)	57 (95.0%)
Fellowship Director			P = 0.116
Yes	57 (6.8%)	1 (1.7%)
No	776 (93.2%)	60 (98.3%)
Department Chair			P = 0.468
Yes	46 (5.5%)	2 (3.3%)
No	787 (94.5%)	58 (96.7%)
Chief of Service			P = 0.208
Yes	83 (10.0%)	3 (5.0%)
No	750 (90.0%)	57 (95.0%)
Editorial Board Position			P = 0.771
Yes	159 (19.1%)	10 (16.7%)
No	674 (80.9%)	50 (83.3%)

^† denotes a one–tailed Mann–Whitney U test.

Research productivity

On average, male surgeons had a significantly higher h-index (14.8) compared to female surgeons (9.6) (P = 0.003). Male surgeons also had higher total numbers of publications (P = 0.019) and were cited more often on average than females (P = 0.03) (Table 3).

Table 3.

Research productivity.

	Male (n = 833)	Female (n = 60)	P-Value
h-Index	14.8 ± 15.9 (0–121)	9.6 ± 10.2 (0–49)	P = 0.003*
Total publications	56.6 ± 93.4 (1–876)	30.9 ± 53.8 (1–338)	P = 0.019*
Total citations	1721.4 ± 3825.1 (0–45,089)	791.1 ± 1595.2 (0–9128)	P = 0.03*

^*P < 0.05, statistically significant.

Discussion

The principal findings of our study were that female shoulder and elbow surgeons are equally likely to serve as fellowship and residency directors, department chairs, chiefs of service, or members of a journal editorial board. Males were more likely to hold a more advanced ASES membership status than female surgeons. Research productivity was found to be significantly less among female shoulder and elbow surgeons, as evidenced by their lower average h-index, number of publications, and number of citations. Overall, gender seems to not be a significantly limiting factor in advancing one's career as a shoulder and elbow surgeon.

In a recent scientific study conducted by Belk et al., ¹⁵ it was determined that 3.3% of orthopedic sports medicine fellowship directors were female. This finding is particularly striking when compared to the results of another study by Filberto et al., ¹⁶ which found that women constituted 18% of all surgical fellowship directors. The stark contrast in these numbers highlights the underrepresentation of women in leadership positions within orthopedics, especially in the subspecialty of shoulder and elbow surgery. Furthermore, an additional study conducted by Patel et al. ¹⁷ revealed that females accounted for only 9.7% of orthopedic residency directors. Interestingly, our study's results showed that there was no significant difference between males and females in holding positions as fellowship or residency directors, department chairs, or chiefs of service. This suggests that women in shoulder and elbow surgery hold equivalent leadership roles compared to their male counterparts. While male surgeons can certainly serve as role models for female surgeons, the identification of a female role model within the field may allow women to feel less discriminated against and possess a greater degree of self-belief within a currently male-dominated field. ¹⁸ The findings of our study are promising indications that efforts to address gender disparities in leadership roles specifically in shoulder and elbow surgery are successful. While the changes may not yet be evident in ASES membership status, a designation that often takes time to achieve higher ranking, the overall trend suggests positive developments in leveling the playing field for women in leadership positions within this subspecialty in orthopedic surgery. No significant difference was found between proportion of male (5.5%) and female (3.3%) shoulder and elbow surgeons holding other leadership positions such as department chair, fellowship or residency director, or chief of service, however, future studies should continue to investigate these differences using alternative data sources.

Hoof et al. ¹⁹ evaluated the h-index scores of 4323 orthopedic surgeons from 160 residency programs across the United States who held positions as assistant professors, associate professors, full professors, department chairs, and division chiefs. The researchers found that in locations where females held a higher proportion of orthopedic faculty positions, the research productivity of females was increased. They also found that females in higher ranks of faculty positions had similar levels of research productivity as males in the same positions, though females were far less represented in these leadership positions and in orthopedics in general. In contrast, the results of this study found that although female shoulder and elbow surgeons had equivalent leadership positions, they had a lower h-index score, fewer publications, and fewer citations than their male counterparts. Further research is needed into understanding why there is this discrepancy. One possible explanation is that we are in the beginning stages of eliminating the gender disparities within the field of shoulder and elbow surgery, and as a result, many of the current female surgeons are younger and earlier in their careers. Number of citations, number of publications, and h-index are all markers of research productivity that tend to improve over the course of one's career. Due to the recent effort to recruit females into the field of orthopedic surgery, it is possible that many of the current female shoulder and elbow surgeons are earlier in their careers when compared to their male counterparts. Other viable explanations for a lesser research output in female surgeons are a lack of institutional support, less resources, more family obligations, or less interest in conducting research. Sequeira et al. ⁵ also explored potential causative factors when discussing the results of their study, in which they found that females had significantly lower rates of first, senior, and general authorship among the shoulder and elbow literature. They cited many other potential causes, such as the relative youth of the shoulder and elbow specialty compared to other areas and females applying for lower-valued grants. Regardless, it would serve our community well to understand and address any potential limitations that contribute to this lack of research productivity for women in the field.

These results lead to further questions regarding why female shoulder and elbow surgeons exhibit equal levels of leadership roles, yet demonstrate lower levels of ASES membership and less research output than male shoulder and elbow surgeons. Additionally, the equal numbers of males and female surgeons in leadership positions is not seen across similarly male-predominant fields in surgery. Fields such as otolaryngology exhibit much lower levels of females in leadership positions. ²⁰ Organizations such as the Ruth Jackson Orthopedic Society (RJOS) serve to ensure that female orthopedic surgeons are afforded the same academic and networking opportunities as males. Evidenced by this study, women, while still making up a much lower proportion of total shoulder and elbow surgeons, are achieving leadership positions at an equal rate as males. The greater academic productivity identified in male surgeons may be a remnant of the long-standing, male-dominated legacy of shoulder and elbow surgery and orthopedics, and thus over time may diminish as newly-recruited female surgeons progress through their careers. While there has been a rise in female shoulder and elbow surgeons in recent years, the difference in number of male and female shoulder and elbow surgeons is so vast that it is improbable that such a gap would be diminished in just a few short years. As such, there is a smaller pool of women in this subspecialty who can serve in leadership positions when compared to men. Despite this, women are more equally represented in positions of leadership such as fellowship or residency directors, department chairs, or chiefs of service than before.

Overall, women still only represent 6.7% of shoulder and elbow surgeons in ASES. Given this low number more efforts should be made to recruit women in this subspecialty. Research productivity and leadership roles are important factors required to obtain advancement in ASES and more efforts should be put forth to address these differences and encourage more women into the field. While pipeline programs and similar organizations are effective at getting women into the field of orthopedics, there is still room to improve the support they receive once they have gone into practice. Further studies could compare the resources and support provided to male and female orthopedic surgeons to identify the root causes of these inequalities more precisely. Additionally, a survey could be sent to women in shoulder surgery to better understand their perspectives on why and how these discrepancies exist.

As with any research, this study is not without limitations that may have impacted the data collected and conclusions synthesized. The sources used to extract information regarding the ASES surgeon education, clinical practice, leadership and professorship positions, and research contributions were heterogeneous between participants. In addition, some metrics including h-index, total number of publications, total number of citations, and current leadership positions held are subject to change at any point in time, meaning that the data which was collected over a 4-month period may be inconsistent. To combat this limitation and minimize selection bias, we randomized the order in which participant data was collected over the 4-month period. Another potential limitation is the accuracy of the information collected. As the online sources used to collect data are not standardized or fact-checked, the accuracy of information gained may have errors that could not be accounted for. To reduce possible inaccuracies, data collected for each participant was compared to the surgeon's personal website or curriculum vitae when available. Similarly, validity of the data collected was monitored by comparing multiple online sources of information for each participant to verify facts and correct any inconsistencies when applicable. Particularly in female surgeons, there exists the possibility of a name change as a result of marriage or a similar circumstance. The authors performed extensive searches for each female surgeon that was identified to mitigate the effects of two separate names on their historic research output. In the instance of identification of multiple names for a single surgeon, research outputs were reconciled. Regarding the sample size of this study, women were underrepresented when compared to the number of men in the ASES database. This small sample size could result in lower power, particularly when detecting differences in frequencies of academic rank and leadership between male and female surgeons. The smaller sample size of women although seen in similar studies was accounted for by including the entire ASES database of surgeons to prevent any gaps in predictive modeling and provide thorough quantitative numbers of the entire subspecialty society membership. Lastly, the authors chose to evaluate editorial board position as a binary measure (yes vs. no), as opposed to assigning a value for each additional position on a separate board. The authors believe this is a more valuable measure of career trajectory, rather than assigning double importance to holding an additional position.

Conclusion

This study found that female gender was linked to significantly lower number of citations, publications, and h-index in shoulder and elbow surgeons but equal presence of leadership positions such as fellowship director, residency director, chief of service, and department chair. These findings indicate that pipeline programs and other concerted efforts to get women into orthopedic surgery seem to be making a substantial difference. Continued focused efforts are still needed to recruit more women into the shoulder and elbow subspecialty and support their academic and research productivity, however, metrics such as number of publications, citations, and h-index may improve over time as female surgeons have more time in the field to conduct quality research.