Breaking Barriers: A Brief Overview of Diversity in Orthopedic Surgery

Abstract

Diversity within the field of orthopedic surgery has been slow to progress, even well into the 21^st century. Despite the barriers broken in 1932 by Ruth Jackson - the first female member of the American Academy of Orthopedic Surgeons (AAOS) - gender, racial and ethnic diversity continues to be lacking. Research has shown there are clear advantages of a diverse physician population, not only in medicine and patient care but in commercial industry as well. Although the representation of females and underrepresented minorities (URM) in orthopedics is increasing, it is doing so at a slower rate as compared to other surgical subspecialties. Targeted efforts have been made to investigate and promote gender and cultural diversity in orthopedic surgery. New programs and initiatives have been developed to promote diversity in orthopedics through mentorship and enhancing visibility of females and URM in the field.

Introduction

The term “diversity” is not easily defined. The more traditional connotation of the word refers to the great variety of differences that exist between people, associated with race, language, culture or gender. In recent years, advocates have expanded the definition of diversity beyond the more obvious dimensions, to include individuals with a myriad of perspectives, social roles and experiences.^1-2 When considering diversity in its traditional sense, orthopedic surgery has the lowest percentage of females and minorities of all medical and surgical subspecialties.^3-5 While females comprise approximately 50% of medical school graduates, they represent only 14% of orthopedic surgery residents.⁶ African Americans and Hispanics comprise 13.3% and 17.6% of the U.S. population, but only 4.1% and 2.7% of orthopedic trainees, respectively.⁶ Furthermore, according to a 2010 study, there were 6.3 male applicants for every female, 13.5 white applicants for every African American, and 14.1 white applicants for every Latino applying to orthopedic surgery residency.⁴ There is a well-documented paucity of diversity in gender as well as race and ethnicity that exist in surgical subspecialties, and this is magnified in orthopedics.

Why is Diversity Important?

The concept of diversity has been increasingly recognized and valued in academia and the workplace. Research in business and commercial industry has shown that diversity in the workplace broadens consumer markets and stimulates economic growth.^7-9 In a survey of over 1,700 companies examining diversity in management, it was found that companies with more diversity earned more revenue from new products and services, especially when females held >20% of positions.¹⁰ In a 2010 study, Joy et al. found that Fortune 500 companies with females on the board of directors had better performance. Further, they found that two of the companies with the best stock market gains (DuPont, Kraft foods) had female CEOs.¹¹ These studies support the idea that within the corporate world, boards perform better when they include people who offer a wide range of skills, perspectives and backgrounds.

With the increased heterogeneity of modern America, many would agree that diversity in healthcare is of paramount importance. Within medicine, physician diversity provides well-documented benefits to patient care. URM have increased health disparities and decreased access to patient care.¹² For example, a recent study showed Hispanic and African American patients are almost 50% less likely to undergo total knee arthroplasty (TKA) than white patients.¹³ Research has demonstrated that underrepresented minority physicians are more likely to serve uninsured patients and practice in underserved areas, leading to improved patient satisfaction and access to care for underserved groups.¹⁴ Additionally, patients are more satisfied with their treatment and their ability to communicate with their provider when they are managed by a physician from their own culture.¹⁴ Bickel et al. found that there are many benefits to recruiting female leaders including improved marketing efforts for the institution, additional healthcare provider options for patients, an increased number of role models for students and residents, enhanced institutional creativity and an enriched institutional culture.¹⁵ Recruiting a diverse medical team is therefore important for the advancement of the medical profession and benefits the health of the population.

Ruth Jackson and the Ruth Jackson Orthopaedic Society

Dr. Ruth Jackson is known as the first practicing female orthopedist in the United States. She was born near Scranton, Iowa and later obtained her medical degree from Baylor College of Medicine in 1928, as one of four women in her class of 164 students. In training, females were not allowed to examine men and had to score 10 points higher to graduate with “equal standing.”¹⁶ After graduation, she pursued general surgery, but was rejected as no internships were available for females. With her path blocked for a career in general surgery, Dr. Arthur Steindler invited her to the University of Iowa to train in orthopedics. Dr. Jackson then decided to pursue a career in orthopedic surgery and finished her residency at the Worcester Massachusetts Memorial Hospital in 1932. She became board certified in 1937, and the first female member of the AAOS.¹⁷ She practiced orthopedics for over 50 years. Dr. Jackson is known to many to be a pioneer who broke down many barriers for female physicians, surgeons and orthopedists alike.

The Ruth Jackson Orthopaedic Society (RJOS) was founded in 1983 as a support and networking group for female orthopedic surgeons. Founding members included Drs. Ruth Jackson, Liebe Diamond, Mary Morden, Sandra Thompson, Jacqueline Perry, and Mary Ann Shannon. Originally a sounding board and socializing group, RJOS has developed into a professional society amassing over 600 members devoted to advancing females in orthopedic surgery. Opportunities such as a mentorship, scholarships, research grants and awards, educational projects, an endowment with the Orthopedic Research and Education Foundation (OREF), and a traveling fellowship program are offered through the society. The mission of the RJOS is to “promote professional development of and for women in orthopaedics throughout all stages of their careers.” RJOS serves as one of the major organizations that exist to promote diversity within the orthopedic community.

Where are we now?

Diversity within the field of orthopedic surgery has been slow to progress, even well into the 21^st century. Despite the barriers broken, gender, ethnic and cultural diversity continues to be lag behind other industries and health care fields. The relative lack of diversity in orthopedics has been a popular topic of investigation over the past 20 years.

In an analysis of data from the American Association of Medical Colleges from 1970 to 2001, Blakemore et al found that the percentage of women in medical school increased from 0.6% in 1970 to 9.0% in 2001.³ This percentage has drastically increased over the last two decades, with women representing nearly 51% of matriculating medical students in 2017.

Although medical schools have achieved balance in gender over the last decades, gender diversity in orthopedic surgery has remained disproportionately low. From 1981-2001, the percentage of female residents who chose orthopedic residency was consistently 0.6% .³ This proportion increased to 0.92% in data from the 2016-2017 academic year.¹⁸ Furthermore, in the years 2008-2009, although 58% of undergraduate students and 48% of medical students were female, only 13% of orthopedic residents and 4% of AAOS fellows were female. At that time, more than 50 orthopedic residencies had an average of less than 10% female trainees over 5 years,¹⁹ which did not change in the following 5 years.²⁰ Currently, females represent only 6.5% of AAOS membership.²¹

Although historically surgical subspecialties are male-dominated, orthopedic surgery has the lowest proportion of female residents and has been the slowest to increase in proportion over time. Compared to other surgical subspecialties, between the 2005-2006 and 2016-2017 academic years, neurosurgery and thoracic surgery had 56.8% and 111.2% increases in female representation, respectively, whereas orthopedic surgery demonstrated a 27.3% increase. This study also revealed that women are much less likely to hold high-ranking academic titles and department chair positions.¹⁸ Given the proportion of females in medical school increased over the time period, these data may imply that the percent increase in female orthopedic surgery residents may be more directly related to the increase in number and proportion of female medical students rather than increased interest in the field.

Studies show female orthopedic trainees perceive gender disparities. In a poll of orthopedic surgery residents about perceptions of gender differences in orthopedics, mentorship by the same gender was a more important positive factor for women as compared to men. Females were more likely to choose orthopedics during clinical rotations, while men were more likely to choose prior to clinical rotations.²² Additionally, a 2010 survey of 76 ACGME-accredited orthopedic surgery programs reported that 2/76 (2.6%) residency program directors were female, with no female department chairs.²³ The findings suggest that mentorship, exposure, and experiences could increase the recruitment of female applicants in orthopedic surgery.

Diversity in orthopedics is not restricted to gender. Throughout history, there has been a paucity of diversity in ethnicity and race as well, although this has been less studied and less clear data exists. Day et al. compared orthopedics to other surgical subspecialties to determine the composition of the workforce according to race, ethnicity and sex that make up medical students, orthopedics residents, faculty and full professors. They found that in the 2006 orthopedic workforce, there were significantly fewer minority orthopedic residents compared with medical school graduates, and comprised a significantly smaller proportion of orthopedic residents as compared to general surgery and neurosurgery residency programs. Furthermore, African-Americans, Hispanics/Latinos, and Asian-Americans were underrepresented among orthopedic faculty compared with their representation in orthopedic residency programs. Okike et al. found that in 2001-2008 females represented 14.5% of orthopedic surgery residents while Hispanics/ Latinos represented 3.8%, African-Americans represented 4.0%, Asian-Americans 11.7%, American Indian/Alaskan Natives 0.4%, and 0.3% for Native Hawaiians/ Pacific Islanders.⁵ These studies are just a few that highlight the gender, ethnic and racial profile of orthopedic surgery compared to both the American population and the profile of U.S. medical students.

Although not exhaustive, this review is meant to provide a brief summary of the limited gender, racial and ethnic diversity in the field of orthopedics. In our overview, we note issues of gender diversity have been highlighted in literature and the media, while we found less clear and complete data on ethnic and racial diversity in orthopedics. Research supports that targeted efforts to decrease ethnic healthcare disparities by diversifying the U.S. physician workforce are needed to ensure high-quality, culturally competent care is provided to all patients.

Efforts to Increase Diversity in Orthopedics

Recent literature suggests that mentorship and early exposure are critical for increasing female and underrepresented minority interest in orthopedic surgery, and targeted efforts have been made to facilitate this change. Several programs have been developed to promote diversity in orthopedics, improving the perception of orthopedics and interest in pursuing a career in orthopedic surgery.²⁴ These programs, as well as RJOS, have been instrumental in supporting and encouraging diversity in the field.

Nth Dimensions was founded in 2006 with the mission of addressing the paucity of females and URM in orthopedic surgery through a longitudinal pipeline program. Pre-medical and medical students are provided with early exposure and hands-on experience, clinical and research opportunities, mentoring and professional development. The program revolves around an internship program targeted for junior medical students with hands-on surgical stimulation and skills workshops. This program has been shown to increase odds of applying to orthopedic surgery residency for females (OR 43.2, p<0.001) and URM (OR 14.5, p<0.001).²⁵

The Perry Initiative is an outreach program founded in 2009, targeted for inspiring young women in high school, college and medical school to pursue careers in orthopedic surgery and engineering. Named for Dr. Jacqueline Perry, one of the earliest female orthopedic surgeons, a hands-on curriculum and lectures are designed to improve participant perception of lifestyle, demands, training and competitiveness of the field. The medical student program produced a match rate of 31% (5/16) in the first class and 28% (20/72) in the second class of participants.²⁴

The J. Robert Gladden Orthopedic Society was founded in 1998 with the mission to increase diversity in orthopedics and eliminate discrepancies in musculoskeletal care. In 1950, Dr. J. Robert Gladden became the first, African American, board-certified orthopedic surgeon. Today, the Gladden Society has over 450 members and is responsible for providing mentorship and professional development opportunities for URM in orthopedic surgery. Initiatives include mock oral exams, research grants, scholarships, and traveling fellowships. Through advocacy efforts, the society promotes the elimination of healthcare disparities in patients with musculoskeletal disorders. Through research and education, the goal of the Gladden Society is to provide culturally competent musculoskeletal care for all patients they serve.

The Women Orthpaedist Global Outreach was founded in 2006 by five female orthopedic surgeons, with a mission of providing free orthopedic surgery to underserved communities worldwide. The group provides musculoskeletal reconstructive care to anyone in need, but focuses on women due to the barriers to receiving treatment and significant burden of life and work in rural communities. Previous mission trips have included various countries such as Nepal, Guatemala, Tanzania, Republic of Congo and Cuba. As part of the program, local orthopedic surgeons and healthcare professionals are trained in orthopedic skills and technologies to improve the health of their communities. Not only do participants in this program provide musculoskeletal care, but they also provide mentorship to young volunteers and diverse populations in the developing countries that they visit.

These programs have the common goal of promoting diversity in orthopedics, as a workforce exhibiting a variety of backgrounds and skillsets produces a more complete, well-rounded approach to healthcare. Stated simply, diversity “increases the overall collective intelligence of the team”.²⁶

Conclusion

The orthopedic community has been making efforts to encourage diversity in the field, yet, disparities continue to exist. Although the representation of females in orthopedics is increasing, it is doing so at a slower rate as compared to other surgical subspecialties. African-Americans, Hispanics/Latinos, Asian-Americans, American Indian/ Alaska Natives and Native Hawaiians/ Pacific Islanders are all significantly underrepresented in orthopedic surgery as compared to their prevalence in the U.S. population.²⁷ While multiple programs are working to promote diversity in orthopedic surgery through mentorship and enhancing the visibility of females and URM in the field, significant work has yet to be done.