Equity360: Gender, Race, and Ethnicity—What’s in Your Knapsack?

Let’s talk about privilege. Let’s talk about white privilege. Want to stop reading already? I get it. I also feel defensive when I hear “white privilege.” It is not my fault that I was born white. I worked hard to get to where I am today.

I may believe that no one gave me anything in life, but the reality is far different. As American feminist, activist, and scholar Dr. Peggy McIntosh writes: “I think whites are carefully taught not to recognize white privilege” [5].

Let’s adopt a spirit of curiosity and seek to gain some understanding of this powerful, hidden force of privilege that impacts every one of us as surgeons and each of our patients.

Racism and sexism are concepts most of us understand. Privilege is harder to comprehend. I believe most of us don’t think of ourselves as privileged since we all experience challenges. But having privilege does not mean one is protected from adversity. Rather, privilege is “a special right, advantage, or immunity granted or available only to a particular person or group” [7].

Dr. McIntosh explored the concept of privilege and described how she saw it “as an invisible package of unearned assets that I can count on cashing in each day, but about which I was ‘meant’ to remain oblivious. White privilege is like an invisible weightless knapsack of special provisions, maps, passports, codebooks, visas, clothes, tools, and blank checks” [5].

I found this metaphor helpful as I contemplated the concept of privilege. I thought about my own knapsack as a white orthopaedic surgeon (ignoring my gender for the moment) and found some items to share:

• No one considers my acceptance into medical school as part of an affirmative action initiative.

• In surgical scrubs, I am never mistaken for someone who works in environmental services at the hospital.

• I can forget my identification badge at the hospital and not be looked at suspiciously by the security guard.

• Portraits of medical leaders at my institution look like me, making me feel part of the group.

• In responding to an in-flight emergency, a flight attendant will not question my medical degree.

• I can discuss situations involving racism without being seen as emotional or self-serving.

• I have never contemplated my white son being shot by police.

I did nothing to earn these provisions. I was simply born white. This is the essence of privilege, an advantage you receive because of your birth circumstances.

Gender also confers privilege. Orthopaedics has been a profession for white men. And though I have been blessed with fabulous mentors, my professional leadership success is almost completely tied to white men who believed in me. The few women before me were not in positions to directly influence my career, but my deep gratitude to them for blazing the trail remains.

Dr. McIntosh writes that men are carefully taught not to recognize the privilege of being a man [5]. As a white woman orthopaedic surgeon, I live in a world that is different from that of my white partners who are men. I imagine the invisible knapsack of my colleagues who are men would have all kinds of goodies:

• Patients and families never have difficulty identifying me as the attending surgeon. I am not mistaken as a nurse.

• Patients never ask me if I am physically strong enough to do the surgery.

• In leadership meetings, my voice is heard. My comments are not dismissed and then resubmitted by another man.

• If I am a father, the mother of my children has a higher percentage of family and household responsibilities (whether or not she is a professional herself), freeing me to greater professional accomplishments.

• Pay equality is not my concern.

• I know I will always be addressed as “Doctor” (which I worked so hard to earn) when introduced at professional meetings.

• I can easily find a mentor as so many leaders are comfortable with me and want to nurture my talents.

• I can speak out against a situation with emotion and know that my emotions will not be perceived to be related to my gender.

Orthopaedic colleagues of color who are men would have advantages arising from the privilege of being a man and disadvantages related to race. Women orthopaedic colleagues of color have both the disadvantage of gender and race or ethnicity.

Yet pretty much everyone can find some personal privilege that they can acknowledge. This is another important aspect of the concept of privilege. A recent quote from Congresswoman Alexandria Ocasio-Cortez highlighted this well: “I am a cisgendered woman [a person whose self-identified gender matches his or her birth sex]. You know, I will never know the trauma of feeling like I’m not born in the right body. And that, that is a privilege that I have—no matter how poor my family was when I was born” [6].

Why does privilege matter in orthopaedics? Privilege supports inequity in compensation with women orthopaedic faculty earning USD 40,953 less than men after adjusting for clinical and research productivity [4]. Privilege favors leadership advancement in medicine for men over women [1]. And privilege supports healthcare disparities, with the Institute of Medicine stating that disparities could not be explained based on clinical criteria or patient preferences but rather explained at the level of systems of health care and discrimination [3].

Each of us can make a difference in addressing privilege. The concept is not to take away something from whites or men but to eliminate the negatives for nonwhites and women. Some specific actions that each of us can implement are:

• Mentor a student who does not look like you. Whether you practice in academia or the community, you can influence a young person to consider a career in orthopaedics. Ask this student about his or her experiences and learn of his or her perceptions.

• If you are in a leadership position, publicly state your commitment to equitable care to your team. Challenge your team to hold you and each other accountable and to call out perceptions of bias.

• Take the Implicit Association Test [8], have your team members take the test and then debrief on your experiences. This is a free test designed to allow an individual to identify their own unconscious biases related to gender, race, ethnicity and obesity.

• Recognize when an act of bias or discrimination has occurred and speak to correct it. At a meeting when a woman surgeon is called by her first name and the men surgeons are addressed as “Doctor”, simply ask for clarity on whether the convention is to address individuals by first name or professional title.

• For those of us who determine or influence physician compensation, pay your team members equitably based on the criteria you set. Men and women orthopaedic surgeons should be paid the same for equal work.

Privilege is not about blame or guilt but rather a recognition that each of us can be advantaged over someone else because of factors outside our personal control. And that advantage creates inequity in our profession and in the delivery of health care. We have an obligation to provide high quality, equitable care to all our patients. To do so we must create a culture of inclusion which will make orthopaedics attractive to diverse students. An inclusive health care workforce is associated with improved access and quality of care for all patients [2]. The future of our profession depends on addressing white and male privilege.

But before we can promote the diversity in our workforce, and even before implementing any of the action items above, it’s important to first consider the following question: What’s in your knapsack?