A roadmap for surgeon leaders in improving gender equity: educational strategies, implementation, and evaluative methods

Abstract

Background:

Gender diversity is lacking in the orthopedic workforce, and patient outcomes are known to be negatively affected when gender inequity exists. Following an unpublished needs assessment, we sought to evaluate participants’ proposed solutions to gender inequity faced by female orthopedic surgeons in Canada and to translate the range of solutions into a medical education model.

Methods:

Open-text responses from a gender-bias survey of Canadian orthopedic surgeons who identified as women were analyzed qualitatively by 2 experts. The questions covered the domain of changes required to improve the work environment. We used the latter 2 steps of Kern’s educational framework as a lens to interpret the data and generate solutions.

Results:

A total of 330 eligible surgeons were approached, and 220 (67.0%) completed the survey. Respondents provided more than 14 000 words of text for analysis. Using the themes of the unpublished needs assessment, we defined broad goals and specific objectives, including raising awareness, establishing an equitable playing field, drawing attention to male privilege, developing effective mentorship, eliminating harassment, and unburdening the second shift. We present solutions via educational strategies and evaluative methods based on Kern’s framework.

Conclusion:

We offer a road map for improving gender diversity in orthopedic surgery, based on survey results from Canadian women in orthopedic surgery, analyzed using a gender bias framework and an educational conceptual framework. We hope that this work will improve the surgical profession and patient care.

Patient outcomes are known to be negatively affected when gender inequity exists in the orthopedic workforce. ^1–6 It is currently predicted that it will take 200 years to achieve gender parity in orthopedic surgery in the United States, where 8% of practising surgeons are female, with only a 2% compound annual growth rate over the last decade.⁷ Recommendations to steepen this rate of change include benchmarking female orthopedic faculty, program directors, and incoming trainees; leading a national effort to help surgeons with academic development; and recruiting female leaders.⁸ An early signal of improvement with directed efforts has been seen in female leadership in course conferences,⁹ podium speakers at national meetings,¹⁰ and editorial board positions.³ However, the percentage of women in these roles remains in the single digits. In Canada, the situation is closely matched, with women making up only 13.6% of the orthopedic workforce¹⁰ (around 25% if trainees are included). Nonetheless, women in leadership positions in academic institutions comprise only 1% of faculty and leadership roles.⁸

Gender diversity is a laudable goal to better serve a diverse population, and surgeons who identify as women are up to the task, with equal or better outcomes than their male counterparts.^2,4–6,11 The author team has created a roadmap for leaders to follow to achieve equity for female orthopedic surgeons. In a recent survey of female orthopedic surgeons in Canada, a distressing degree of ongoing workplace inequity and burnout was reported,¹² highlighting situations that were further exacerbated by the COVID-19 pandemic, in which female working parents were disproportionately burdened.¹³ This index publication revealed themes of unequal standards, male privilege, lack of mentoring, hostility and harassment, and work–life integration, which are consistent with the ongoing expression of gender equity issues in the medical literature.^14–19

This paper follows an unpublished needs assessment and uses qualitative methods and Kern’s conceptual framework²⁰ to develop a way forward for leaders. For the needs assessment, the authors analyzed open-text responses to a question relating to barriers experienced by female surgeons. A thorough analysis of the responses was conducted using Kern’s first 3 steps in curriculum development: problem identification, needs assessment, and the development of educational goals and objectives. The goals identified included raising awareness, establishing an equitable playing field, drawing attention to male privilege, developing mentorship and leadership programs, eliminating harassment, and unburdening the second shift.²¹ Each of these goals was further specified with 19 measurable objectives. In the current paper, we analyze the solutions proposed by respondents to provide educational strategies and discuss implementation and evaluation, closing the loop on Kern’s 6 steps of curriculum development.

In this study, we sought to evaluate participants’ proposed solutions to gender inequity faced by female orthopedic surgeons in Canada and translate the range of solutions into a medical education model.

Methods

The methods have been previously described in the index paper.²² In brief, open-text responses from an online survey²³ distributed to Canadian orthopedic surgeons identifying as women were analyzed.²² Two open-text questions were posed to respondents, including obstacles experienced and changes required; the first question informed the needs assessment and goals and objectives, and the responses to the second question are analyzed herein. Next, 2 qualitative experts used a constant comparative technique,²⁴ took multiple passes through the data,²⁵ met several times to reflect on biases, and used a grounded theory approach to develop themes.²⁶ NVivo 12 (QSR International) was used to facilitate this process. Next, using Kern’s educational framework²⁰ as a lens to interpret the data, we considered the latter 2 of 3 steps of the framework, and generated solutions from the respondents allowed authors to pose educational strategies (step 4) and evaluation strategies (step 6).

Ethics approval

The University of Calgary research ethics board approved this study (REB21-0201).

Results

A total of 330 eligible surgeons were approached, and 220 (67.0%) completed the survey. Participants provided open-text responses with more than 14 000 words of text, documenting changes that could improve the workplace. The demographic characteristics showed a preponderance of surgeons who were married (n = 146/219, 66.7%), in their thirties (n = 111/219, 50.7%), in active practice (n = 174/219, 79.4%), in academic centres (n = 122/219, 55.7%), and of North American or European descent (n = 225, 85.6%; respondents could select more than 1 category).

Responses were analyzed thematically, alongside the “obstacles experienced” data, and were considered in terms of their alignment with the 5 themes previously identified. The solutions were further mapped to the 6 goals and 19 objectives described in the index paper.²² Table 1 provides a comprehensive curriculum matrix of general goals with specific objectives, provides additional supportive quotations from participants, and delineates a variety of educational strategies. The results below offer a high-level analysis of the results, organized by goals.

Table 1.

Alignment of goals, objectives, proposed solutions, and educational methods

Goal	Objective	Participants’ proposed solutions	Educational strategies
A. To raise awareness of the lived experiences of orthopedic surgeons who identify as women	1. To identify gender disparity in surgical departments	“Increase awareness of implicit bias and develop mentorship and sponsorship programs.” (P159) “Talk about it — gender bias!” (P13) “The COA needs to have more visible women in leadership positions. It is perceived as an old, white male organization.” (P84) “Awareness training for men would help — it seems like most of them ‘know’ that they can’t say certain things anymore but it seems as though now they just say, ‘this isn’t politically correct but …’ and say it anyways. They don’t understand the impact of their words.” (P149)	Interview members and report back. Survey members and report back. Conduct focus groups and report back.
	2. To formalize and execute a plan to improve EDI in the departments and sections	“Have repeated training and seminars. As annoying as it may seem … can’t just accept it.” (P97) “Education about EDI workplace standards.” (P31) “More education/learning opportunities around diversity in orthopaedics.” (P9)	Study university and hospital guidelines. Conduct city-wide rounds reviewing these documents. Write a department-specific hiring practices document for circulation that puts a local focus on addressing local culture and practices.
	3. To choose champions in EDI	“Develop male champions for gender equity.” (P136) “Also work on educating and exposing implicit bias and hidden curriculums as this has the potential for an immediate effect. Self-reflection and exposure of this I believe would be helpful as many male colleagues do not believe they are attributing to the hidden curriculum and are unaware of the implications of certain behaviours.” (P67) “I think this really rises and falls on mentorship and allies. People in leadership need to model this, reward this in their working groups and show that this adds value.” (P146)	Announce an opportunity to join a champion team. Provide resources for education on the difficulties faced by their peers.
B. To establish an equitable playing field for orthopedic trainees and surgeons Theme: Unequal standards	4. To measure and estimate the pay difference as it relates to gender	“Acknowledge and address the gender pay gap in medicine/surgery.” (P137) “The profession is currently very exploitative of female trainees and staff — needs to be more objective accountability of who is doing the work, who is taking credit, and who is supporting (or under-supporting) qualified personnel.” (P135) “I believe women are more sensitive in their approach with patients, will truly care more and spend more time talking to their patients, getting to know them. I don’t think this is an orthopedic profession thing. I think this is just the nature of being man versus woman. I realize I do this in my practice. I’ve tried to spend less time. I’m not happier when I do so, on the contrary, I don’t feel like myself and I enjoy my work less when I do. So, I’m a bit slower in clinic than my male counterparts. It is what it is. We each have our own styles. No one is pressuring me to spend less time with patients.” (P30) “More equitable payment schedule — more women in certain subspecialties that are poorly paid (more women in [pediatrics], foot and ankle, etc.).” (P56)	Quantitate share of unpaid work, dead-end work.27 Review glass cliff28 scenarios in leadership.29
	5. To equalize the types of asks of female surgeons	“Stop asking females to do the more sensitive jobs, i.e., once I got asked to attend a family meeting of a patient I didn’t know at 7 pm when NOT on call because 2 males were on call (1 who knew the patient) but wouldn’t be sensitive enough to discuss their probable cancer diagnosis.” (P161) “More equal sharing of administrative duties.” (P129) “Teach us about our unconscious biases. If we don’t know what it is that stops us from valuing what women think or say, how can we change it?” (P140)	Audit unpaid work. Quantitate dead-end work.27 Assign EDI representative to monitor and evaluate grievances.
	6. To critically analyze past hiring practices To socialize a hiring-monitor role among more surgeons	“I find more female surgeons gravitate toward community hospitals, likely for lifestyle reasons as well as to get away from the boys club mentality in the cities.” (P26) “Directed efforts to hire diverse trainees and surgeons.” (P171)	Job shadow. Run job fairs. Review hiring practice documents. Review the history of hires. Train a team of EDI champions.
	7. To appraise promotion criteria with an EDI lens	“There is a huge barrier to promotion and leadership for women in surgery. I have put myself forward and met resistance at every turn. Currently, I just feel like giving up — hoping I have made space for the next generation, punch the clock but remain partially engaged, and pursue other interests outside of work.” (P166) “There should be an overhaul of promotion criteria with the evidence of barriers women face — i.e., you make the rules and pass the judgement can’t be the case.” (P166) “Continue to base advancement on merit not identity politics.” (P2)	Overhaul promotion criteria. For instance, there needs to be other measures of merit than “invited speaker.” This could include teaching, service, committee work, and work with international organizations as being on par with being an invited speaker.
C. To draw attention to male privilege and open membership to any “hidden” club Theme: Male culture	8. To sensitize meeting, rounds, and administration scheduling to accommodate various preferences	“Acknowledge the systemic biases that make it harder for women and BIPOC people to do the same job as white men, incorporate training in implicit bias in training and maintaining Royal College certificate.” (P116)	Enact EDI policies. Run implicit bias courses linked with professional development activities or accreditation of institutions. Change rounds, clinic, and OR start times. If this is not feasible or desirable based on the backlog of surgeries, then a more flexible and supportive approach for surgeons with young children could be devised. For instance, child care could be provided by the hospital and prioritized for doctors with early and late hours. OR lists could also be shared. Model flexibility in start times of meetings. Revamp the work week with creative design mindset, rapid prototyping, and fail early approach.
	9. To curb language and practices from defaulting to male	“Women in leadership and actionable EDI policies. Not good enough to go through the motions of creating policies. Need to revamp the culture to create a safe environment for working and to report inequity (does not exist now); need more accountability. Action needs to be taken if inequities are reported, supported by the highest level of leadership in medicine (department head, hospitals; dean, Faculty of Medicine) and at universities (president).” (P25) “Stopping the stupid jokes about women.” (P71)	Run awareness sessions. Provide a suggestion box for anonymous concerns with a mechanism for reviewing and responding. This could take the form of an online university or hospital-based system where confidential, anonymous, or witnessed mistreatment can be reported, with clear accountability of leadership for such reports. There should be an ombudsperson for each major hospital, who can assist with coaching and remediation support for faculty identified and desiring of support to result in more respectful, inclusive, and compassionate communication and conduct.
	10. To be purposeful in flattening social exclusion at meetings, conferences, and dinners.	“Ensuring female residents are provided with equal opportunities for advancement even if they are not ‘buddies’ with the staff.” (P123) “Give women a seat at the table. Not just at formal speaking events, but in social circles.” (P140)	Raise awareness of the impact of social exclusion among surgeons. Consider options such as assigned seating, buddy system, or purposefully randomizing seating.
D. To develop effective mentorship and leadership programs for women in orthopedics Theme: Lack of mentoring	11. To create support networks for surgeons on the margins	“Flexible hours for committees/meetings that don’t fall during family time (i.e., 5–7 pm), and acceptance of home/family duties as ‘work.’” (P60) “Increase opportunities for women in leadership — will require an equitable culture — a culture change towards equity and inclusion. Currently medicine set up for man with a wife at home to help, need to change culture so that all have equal opportunity at work.” (P98) “Create support networks for women in orthopedics, particularly older women who didn’t have the luxury of female colleagues during their training.” (P45)	Develop mentorship programs that include nonsurgical and other surgical specialties. Create a national organization of female leaders in orthopedics. Run female orthopedic retreats.
	12. Create a leadership pipeline by identifying, training, and supporting female surgeons into leadership and mentor positions	“Gender parity in high level roles.” (P168) “Additionally, there could be a national mentorship program for orthopaedic trainees to set residents/fellows up with mentors in leadership positions.” (P82) “Leadership courses, having female ortho groups/retreats.” (P154) “Increased support for formalized leadership training for female colleagues.” (P147) “Encourage and support women to apply for leadership positions.” (P37) “I think it would also help encourage female medical students become interested in orthopedic surgery and choose my training location for residency if they saw female attending staff.” (P70)	Send women to leadership courses. Increase board work by women. Increase leadership positions for women in committees. Solicit input and creative ideas in situations of maternity or sabbatical. Increase locum opportunities to also step into leadership roles as an interim. Increase mentorship or community of practice opportunities with surgical and nonsurgical colleagues.
	13. To define avenues to increase the appeal of the specialty to women	“Making efforts into promoting orthopaedics to female medical students which might balance the male–female ratio.” (P86) “Create a systematic formal process whereby female leaders are in synchrony across Canada. Every orthopaedic department should have a female department head from the years 2022–2025 inclusive, and all should be connected by regular COA-supported video conferences. This 100% female cohort should be supported and studied by a centralized professional workplace equality taskforce to analyze the trouble spots.” (P142)	Run job fairs. Provide shadowing opportunities. Reach out to other specialties to debunk myths of women not being appropriate for surgery, surgical specialties being unfriendly to women, and so on.
E. To stop the harassment experienced at the workplace Theme: Hostility and harassment	14. To illustrate that harassment is real and present to the RCPSC, colleagues, allied health care practitioners, and patients	“Public campaigns (re) women in surgery would be helpful.” (P47) “Patients need to accept female surgeons as equals as well as our own medical community.” (P110) “Treat female residents same as males. It has to come from a change in society as well.” (P108)	Run social media campaigns. Erect signs in the hospital. Run webinars. Audit the OR and the ward for behaviours — take the “temperature” of the room. Have meeting monitors to provide language and equity training. Add “equity in the OR” in the preoperative briefing to increase patient and provider safety. Demonstrate solidarity with talismans, such as pins and lanyards. Consider ways to measure harassment. Measure and report back in a PDSA type of format in a formal manner with the hospitals and clinical units. Use universities as advocates, sharing data and collaborative action plans.
	15. To arrange interdisciplinary opportunities with nursing and other allied health	“Address workplace safety — eliminate toxic historic behaviors and ensure patient safety guides all decisions.” (P91) “Intervention to nursing staff (they are exquisitely more difficult to female residents than males).” (P77) “Educate older orthopaedics and residents to the fact that women are now part of the job. Educate nursing staff about the same thing!” (P157)	Explore the issue of harassment by allied health. Improve nurse awareness of the issue. Provide female surgeons with the skills to have critical conversations with the health system. Empower seasoned surgeons and anesthetists to stand up and say no to any witnessed abuse of other surgeons.
	16. To develop toolkits to assist with acute situations	“Understanding by male physicians the barriers women face and ways to assist/tackle these and intervene when they witness them.” (P35) “I was harassed by certain OR nurses, and usually my last case would be cancelled as the chiefs would be running 2 rooms and not done on time, there would be a nursing shortage, so my last case was cancelled. It would be rescheduled during my 80 patient clinic day.” (P95)	Invoke a policy for harassment. Collect stories to breathe life into the issue for disbelievers. Review and adapt harassment policies. Create a mechanism for early reporting of overtly inappropriate behaviours toward women. Analyze the impact of past abuse.
F. To unburden the second shift for women Theme: Work–life integration	17. To normalize fertility and parenthood planning discussions, including the importance of reducing a surgeon’s stress during her maternity period	“In residency I think that paid paternal leave matching maternal leave would create more equity in terms of how young female residents are viewed when they take time off to start a family.” (P22) “Support families by inviting them at events, and being flexible with schedules.” (P164) “An open policy for mat leave. Could be discussed in the interview process so we don’t feel bad when we get pregnant.” (P129) “Ensure all orthopedic surgeons get paid parental leave if they desire.” (P11)	Seek out intimidation, hidden or overt, around family planning. Facilitate the development of shared practices and locums. Provide paid family leave.
	18. To transform the concept of a surgeon’s daily schedule	“Child care at work.” (P17) “Supporting models of practice that are more flexible for everyone will promote everyone’s well-being and destigmatize wanting to invest time elsewhere in one’s life (good for both men and women).” (P104)	Enact staggered OR start times. Create other opportunities for surgeons to teach that avoid an early start, such as shared OR slates, flex slates, rotating fixed OR days.
	19. To introduce flexibility with the career cycle as it maps to family needs	“Allowing time sharing appointments.” (P59)	Develop part-time opportunities (job-sharing models). Map nearing retirement surgeons with those entering their reproductive years.

BIPOC = Black, Indigenous, and people of colour, COA = Canadian Orthopaedic Association; EDI = equity, diversity, and inclusion, OR = operating room; PDSA = Plan-Do-Study-Act; RCPSC = Royal College of Physicians and Surgeons of Canada.

Educational strategies

Kern’s fourth step involves the development of educational strategies. These strategies require educators to choose learning methods to deliver content to their key partners. Educational strategies need to be feasible, aligned with the goals and objectives, and involve diverse delivery methods, which will increase engagement. Measuring the impact of educational strategies is linked to clear goals and objectives (a key feature of step 6).

Goal A: To raise awareness of the lived experiences of orthopedic surgeons who identify as women

Participants implored that we “bring awareness to our male colleagues that this problem actually exists” (P52). Specific strategies suggested included running educational sessions and seminars, as well as developing allies and champions within the department. Story-telling was a critical delivery method to animate some of the hostilities experienced and to demonstrate the unique challenges faced by female surgeons. Sharing circles were offered as an avenue to acknowledge “what has been done openly and transparently so that changes can be introduced. You need stories before, to drive processes, to ensure it does not happen going forward” (P31).

Goal B: To establish an equitable playing field for orthopedic trainees and surgeons

Many of the solutions provided by the respondents spoke to unpacking the expectations placed on female surgeons because of their presumed communal qualities. For example, unequal standards around the phenomenon of being expected to do “dead-end work”²⁷ was solutioned by assigning “more equal sharing of administrative duties” (P129). Another participant considered that her gender was used as a crutch by others.

Stop asking females to do the more sensitive jobs; i.e., once I got asked to attend a family meeting of a patient I didn’t know at 7 pm when NOT on call because 2 males were on call (1 who knew the patient) but wouldn’t be sensitive enough to discuss their probable cancer diagnosis (P161).

Multiple suggestions were proposed to improve equity and solve some of the barriers that begin at inception of planning a pregnancy and flow through to each successive step of a woman’s reproductive and child-rearing years. An option frequently voiced involved normalizing maternity leave via policies by ensuring their male colleagues could also take paternity leave. “I think that paid paternal leave matching maternal leave would create more equity in terms of how young female residents are viewed when they take time off to start a family” (P22).

Another frequently mentioned imbalance in the playing field was the pay gap. Some alluded to this being due to taking more time with patients, generating fewer consults and fewer operative cases. One surgeon suggested “payment for longer duration consults/follow ups, since women spend more time with patients, counsel patients more thoroughly, resulting in better patient satisfaction and outcomes” (P56). Another hypothesis was that women took on unpaid work in teaching, and administration; a participant suggested the attainment of “[i]ncome equity either by creating pay for research/admin roles or salaries” (P133).

Goal C: To draw attention to male privilege and open membership to any hidden club

Participants entreated leaders to put an end to the “boys club,”³⁰ calling for surgeons to “actively de-promote the culture of ‘jocks’ and ‘bros’ in the field” (P24). This request included attention to work-sanctioned or after-hours social events, whether journal clubs or golf afternoons, with a plea to “change the mentality that it’s normal to have a boys club to a mentality where the normal is everybody’s equal” (P163). Another concern around male privilege was seeing the workday from a traditionally male lens, with petitions to “be open to creative practice set ups to allow people to value family as well as work” (P45). Women voiced that some peers were oblivious to different demands on their time, describing a “male resident [who commented] openly about and widely my lack of work ethic because clinic started half hour later than other surgeons (because of child care drop off)” (P99).

Goal D: To develop effective mentorship and leadership programs for women in orthopedics

Mentorship was identified as a gap, exacerbated by the paucity of female leaders in the Canadian orthopedic workforce. Suggestions for improvement spanned the immediate, short-term, and long-term horizons. With respect to direct action, efforts were suggested toward the development of a “true mentorship program. Residency and also early career. Maybe even mid-career” (P85). In the short term, participants suggested identifying future leaders who would then “mentor and support other women” (P137). The distant horizon centred around increasing the appeal of a presently male-dominated specialty, by “making efforts into promoting orthopaedics to female medical students which might balance the male–female ratio” (P86).

Leadership was also identified as a challenge requiring solutions. A short-term solution included “[i]ncreas[ing] females on conference panels and in leadership positions when this is earned” (P80). Policy mandating parity in leadership positions would improve who sits around the table, ensuring “minimum quotas of women in leadership so we can break through #morethanone” (P166). Attention would need to be paid to the female burden of home demands, requiring “[l]eadership/committee meetings times that take into consideration members with family obligations” (P66). Another participant expressed that both men and women who are patriarchal need to be overcome to “abolish organizations run solely by men and patriarchal women. Women should be at every single table making every single decision and they should not be the women who have been complacent and willing participants in the oppression of non-male surgeons” (P143).

Goal E: To abolish the harassment experienced at the workplace

Two main sources of hostility were identified: allied health professionals and surgeons. The most frequently cited source was from nurses, both in the operating room and the ward. Copious examples of abuse were provided, and participants pleaded for “nursing and allied health education on biases and professionalism around gender issues in the workplace” (P35). Another proposed solution engaged male advocates and denounced turning a blind eye, asking that “[m]ale colleagues pay attention to the nurse abuse that female surgeons experience and actually do something about it” (P20).

The second main experience of hostility was “rampant misogyny and sexual harassment” (P143). One orthopedic surgeon pleaded for leaders to “create and enforce an environment of zero-tolerance with respect to sexual harassment/discrimination” (P93). Moving forward, solutions require strict policies around harassment, a safe place to disclose, and support from leaders after disclosure to protect career and family from repercussion. An unintended consequence of the #MeToo movement was male doctors feeling unsafe mentoring women; one institution described systems-level strategies to avoid gender-based neglect in mentoring.³¹

Goal F: To unburden the second shift from women

Looking past the recommendation for socialization of parental leave for both genders, women still felt distress balancing the roles and responsibilities of being a surgeon while experiencing overload at home. Having access to child care at work was a common request, along with a more general petition for “better support for family and work to co-exist, and some degree of understanding and leniency that women may have children and have responsibilities outside of work” (P120). Multiple respondents wanted more flexibility in the scheduling of early-morning rounds and teaching, in general, with “more flexibility in the work place, with start times in OR, meetings, and rounds to accommodate both men and women who want to be with their families” (P95). Another suggestion included job-sharing opportunities that could flex with the needs of various ages and stages of male and female surgeons in the department. “Maybe 2 female orthopedic surgeons could share a full-time practice and work half the time during those precious moments” (P43).

Discussion

In the process of designing a curriculum and enacting it, there comes a moment where the team creates solutions (based on data in specific parts of the cycle of development) and provides generative solutions to move the learning forward. It is at this point, in the Kern framework, where the authors have collated the data from front-line context experts (female surgeons), using educational design principles (frameworks) to build out a template for change allowing teams and leaders to choose how to implement and measure change within their own context. Herein, the last 2 steps of the Kern framework — implementation and evaluation — are derived based on the data presented in the index article²² and the current article.

Implementation

This step takes the theoretical strategies and converts them into action. Implementation requires obtaining political support, garnering resources, introducing the curriculum through knowledge translation activities, piloting on a receptive audience, refining the curriculum, and then rolling it out more broadly.³² The specific strategies offered in Table 1 involve engagement of multiple key partners — the national orthopedic association, universities, surgical departments, nursing and allied staff at local hospitals, and the public. No open-text responses from the participants referred to implementation specifically; thus, Appendix 1 (available at www.canjsurg.ca/lookup/doi/10.1503/cjs.006324/tab-related-content) is provided for other educational strategies and diverse, creative methods that leaders can choose from as they implement in their facility. Each institution will have a local flavour that will affect implementation, and each leader will need the help of a team of educators who are advocates and allies of equity, diversity, and inclusivity to implement these ideas. Given the number of changes that may be required, and the inertia of culture change, a creative design-thinking approach may be optimal,³³ involving iterative steps of rapid prototyping and quick failure, to avoid wasting time in planning and organizing pedagogically heavy material that then misses the mark. An implementation scientist could also provide needed guidance to oversee and direct the team’s efforts.

Evaluation and feedback

Both individuals and the change strategy require evaluation, which can be implemented as feedback for learning (formative) or assessment of learning (summative). It is an opportunity to look at the efficacy of the learning strategies, as well as the resource needs if there are areas needing improvement. It is imperative that leaders and the medical community implementing learning solutions articulate their evaluation strategy upfront. Participants did not comment specifically on the evaluation of educational strategies, but the 19 objectives provided are clearly defined, improving the ability to evaluate the effectiveness of interventions.

A variety of educational strategies are presented in Table 1, and when they are implemented, the initial evaluation should be formative, as changes in culture and behaviour take time. It should aim to determine whether learning has happened, whether the end-user responded positively to the intervention, and whether the users felt there was a change in their knowledge and behaviours. Participants should recommend any changes that need to be made to the curriculum, what additional resources may be needed, and where resources could be better used or directed. Ultimately, a summative evaluation of the program and the participants should be reviewed by the positive impact of provider health and patient care, an ultimate goal of medical education — improving outcomes. As this will take a long time to be realized, proxy outcomes will need to suffice in the short term, such as numbers of women in various positions, successful development of job-sharing, transparent allocation of operating room time, repeat surveys, and targeted focus groups. A model such as the logic model by Van Melle³⁴ can be used, in which evaluation is planned a priori, with deliberate short-, medium-, and long-term outcome measures. At times, using a business model approach of key performance indicators and timelines links goals, outcomes, and teams to a dashboard tactic that is reviewed iteratively.^35,36

Gender diversity is known to improve workplace outcomes, ³⁷ and the operating room is no exception, with equal or improved outcomes seen in surgeries performed by women.^2,4–6,11 Parallel to orthopedic surgery, many subspecialties are working on strategies to improve gender disparity. ^38–43 This manuscript presents educational solutions for the gaps eloquently expressed by our female membership in Canadian orthopedic surgery.

Diverse surgeons can help mitigate the gender differences in quality of care — for instance, the lower utilization of joint replacement in female patients⁴⁴ is a finding that is seen across many areas of medicine.^45–51 However, many steps are needed to enhance the female orthopedic workforce and make the workspace equitable. Leadership will need to put considerable effort into the process. Moreover, the process will take time — once the problem is acknowledged, addressing issues such as male privilege and social exclusion of women will create discomfort and potential yearning for the status quo.

An area of challenge will be addressing the underemployment of existing female surgeons, related to unequal new patient referrals, or referrals that are complex, time-consuming nonoperative cases.^52,53 The concept of the second shift was introduced in the results. The second shift refers to the work that women have to do after their workday, primarily encompassing caregiving and other work in the home.²¹

Another difficult challenge is the pay gap. Many participants experienced reimbursement differences, similar to a recent analysis showing female orthopedic surgeons earning $60 000 less annually than their male counterparts, even when controlling for caseload, days worked, and complexity of cases.^54,55 Additionally, there remains the challenge of addressing hostility and harassment, a barrier that causes much angst among the respondents. Although there were several alarming cases of stalking and sexual abuse by colleagues described within the open-text responses, the preponderance of hostility was experienced at the hand of nursing staff. Interprofessional conflict and the resultant harsh penalties encountered by female surgeons if they react have been linked to burnout,⁵⁶ another key finding of the index paper in this series.¹⁰ This finding is supported by the results of Giglio and colleagues, who highlight harassment in orthopedic surgery originating from peers and patients.⁵⁷

A strategic plan has been published by the Canadian Orthopaedic Association (COA), outlining actions needed to be initiated within the orthopedic profession in Canada. ⁵⁸ The current work was completed independently of the strategy outlined by the COA. However, comparing these findings with those presented by the COA reveals remarkable overlap, for instance removing gender-specific barriers to advancement, educating the team to mitigate unconscious bias, supporting equity to aid in work–life balance support, and ensuring a gender-diverse leadership structure. Our data-driven approach supports the initiatives outlined by the national association and will hopefully provide more support for change.

We studied the field of orthopedic surgery in this article, but we posit that the orthopedic workforce is not alone in gender disparity. Considerable gender disparities exist across all surgical specialties, and we advocate that our learnings could be applied to any surgical subspecialty in which unequal female representation exists.^28,59

Limitations

The decision to analyze the open-text responses was not decided a priori; ideally, the qualitative methodology would have been established in advance of data collection. Once armed with the data, however, the approach was consistent with qualitative rigour. There is limited information on the intersectionality of gender, race, or other factors, as there was little endorsement of the same by participants. In addition, the participants responding to the survey were orthopedic surgeons working in a Canadian context, and these findings may not be generalizable to other surgical specialties. However, evidence exists that shows gender disparities in other surgical specialties.^19,28,60 Finally, male orthopedic surgeons were not interviewed, and this group may offer a new perspective on the data and their interpretation. The study team did, however, review the data with a male leader in orthopedic surgery as a check-in on our biases early in the analysis stage. This leader reviewed all the qualitative data and provided a summary of what he perceived from the respondents. We discussed his perceptions and noted the concordance with our analysis.

Conclusion

This article offers a road map for improving gender diversity in orthopedic surgery, based on survey results from Canadian women in orthopedic surgery, analyzed using gender bias theory and an educational conceptual framework. The authors hope that this work will improve the surgical profession and patient care.