How Well Represented Are Women Orthopaedic Surgeons and Residents on Major Orthopaedic Editorial Boards and Publications?

Abstract

Background

Recent studies indicate that women are substantially underrepresented as orthopaedic surgeons and residents compared with other specialties in medicine and medical school. The reasons for this are multifactorial and not completely understood, but previous studies suggest that women may be attracted to fields in which they have female role models. Given that women interested in academia and research may use female editorship and authorship as a proxy for female representation in orthopaedic surgery, we wanted to examine the proportion of women represented in orthopaedic journals and determine if it reflects the distribution of women in orthopaedic surgery as a field. We further wanted to understand if this representation has changed over time in the setting of a slowly shifting gender landscape within orthopaedic surgery.

Questions/purposes

(1) How are women orthopaedic surgeons and residents represented in orthopaedic journals compared with men? (2) Have these proportions changed in the past two decades in light of relatively new efforts to recruit women to the field of orthopaedic surgery?

Methods

The gender composition of editorial boards and first and last authors were obtained from the 1997, 2007, and 2017 volumes of the following journals: The Journal of Bone & Joint Surgery (JBJS), the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), and Clinical Orthopaedics and Related Research® (CORR®). Gender neutral names were searched to obtain a picture to ensure proper tallies.

Results

The total combined amount of women first and last authors increased from 88 of 1450 (6%) in 1997 to 152 of 1912 (8%) in 2007 to 723 of 5391 (13%) in 2017. Similarly, three of 113 (3%) editorial board members were women in 1997, three of 105 (3%) were women in 2007 and 10 of 107 (9%) editors were women in 2017. Of note, 0 out of 9 editors-in-chief were women.

Conclusions

Based on the current percentage of women orthopaedic surgeons and residents, women are represented equally or in greater numbers as editors and authors in JAAOS, JBJS, and CORR. This may be in part due to women orthopaedic surgeons entering academic medicine at a greater rate than males.

Clinical Relevance

Orthopaedic surgeons serving as mentors to prospective female applicants can cite female representation on editorial boards and as authors as an example of gender parity in the field. Additionally, active orthopaedic surgeons who are women interested in these leadership positions should be encouraged that these opportunities exist, regardless of gender.

Introduction

Less than 1% of women medical residents in the 2016 to 2017 academic year were enrolled in an orthopaedic surgery residency, a percentage that has changed very little in the past decade [5, 6]. Although the proportion of women orthopaedic surgery residents has increased from 11% to 14% over the past 10 years, this increase is substantially less than most surgical specialties [6]. Other competitive surgical specialties, such as plastic surgery and otolaryngology, have a much higher proportion of women in their ranks [7, 11]. Possible factors that may dissuade women from entering the field of orthopaedic surgery include the perception that too much physical strength is needed and a lack of mentorship [10, 13]. Additionally, a recent analysis of salaries among surgeons found that discrepancies in the compensation between men and women orthopaedic surgeons are among the most severe, with a difference of USD 40,953 persisting after adjusting for faculty rank, age, years in practice, specialty, NIH funding, clinical trial participation, publication count, total Medicare payments, and graduation from a medical school ranked in the top 20 by US News and World Report [9].

With the publication of these gender disparities in the past decade, there has been substantially greater emphasis on recruiting women as prospective orthopaedic surgeons. Groups such as the Perry Initiative and the Ruth Jackson Orthopaedic Society offer a variety of mentorship programs, workshops, and scholarships to help increase the presence of women in the field. Although these groups and initiatives have been successful thus far in ameliorating the paucity of women in orthopaedic surgery, much room for improvement remains [12]. A recent study [8] indicated that both male and female graduating orthopaedic surgery residents have similar career aspirations. Therefore, the number of females represented on editorial boards and in authorship should be proportionate to the number of active orthopaedic female surgeons. Despite this, no study has determined if these female graduates’ aspirations transpired as planned. Similar to how salary discrepancies may discourage women from entering the field, this study may offer further insight into some other possible self-perpetuating and dissuading factors why women do not choose orthopaedic surgery as a career.

Therefore, we asked: (1) How are women orthopaedic surgeons and residents represented in orthopaedic journals compared with men? (2) Have these proportions changed in the past two decades in light of relatively new efforts to recruit women to the field of orthopaedic surgery?

Materials and Methods

In this retrospective study, we assessed editor gender from three major orthopaedic journals from 1997, 2007, and 2017. We evaluated the Journal of Bone & Joint Surgery (JBJS) volumes 79, 89, and 99; the Journal of the American Academy of Orthopaedic Surgeons (volumes 5, 15, and 25; and Clinical Orthopaedics and Related Research® (CORR®) volumes 334-345, 454-465, and 475. Overall, this included 48 issues of JBJS, 30 issues of JAAOS, and 14 issues of CORR. In 1997, we included JBJS Editor and Chairman and Board of Associate Editors; JAAOS Editor-in-Chief, Associate Editors, and Editorial Review Board; and the CORR Editor-in-Chief, Deputy Editors, and Associate Editors. In 2007, the JAAOS Associate Editor category was renamed Deputy Editors, while categories remained the same for the other journals. In 2017 categories included JBJS Editor-in-Chief, Board of Deputy Editors, Board of Associate Editors; JAAOS Editor-in-Chief, Editor Research, Deputy Editors Review, Deputy Editors Research; CORR Editor-in-Chief, Senior Editors, Deputy Editors, and ABJS Member Associate Editors. The following categories of editors were excluded: non-MD positions, editors emeriti, consulting/advisory editors, and international consulting editors.

The genders of the first and last authors of articles that appeared in the issues collected for editorial-board analysis were also tallied. In rare instances when consortiums/organizations were listed as last authors from multi-institutional studies, the second to last author was counted as the last author. Authors of single-author articles were counted as first authors only. When men and women orthopaedic surgeons had gender-neutral names, we searched online for the surgeon to locate supplemental information or a photograph. Outcomes included the total number of women editors, first authors, and last authors from each journal, in each year tested. Total authors for a particular year combined both first and last authors from each journal. Total editors combined the individual number of editors from each journal. The years assessed were chosen for convenience to represent a 20-year timespan.

Results

Among authors in JBJS in 2017, 50 of 400 (12%) first authors and 39 of 320 (12%) last authors were women (Table 1). Likewise, in JAAOS, 88 of 609 (14%) first authors and 60 of 596 (10%) last authors were women; in CORR, 290 of 1848 (16%) first authors and 196 of 1618 (12%) last authors were women. During this time, two of 34 (6%) JBJS editorial boards members were women. In addition, two of 22 (9%) JAAOS and six of 47 (4%) CORR editors were women. The years 2007 (Table 2) and 1997 (Table 3) had a similar breakdown of authors and editors per journal.

Table 1.

Gender of authors and editors for JBJS, JAAOS, and CORR in 2017

Table 2.

Gender of authors and editors for JBJS, JAAOS, and CORR in 2007

Table 3.

Gender of authors and editors for JBJS, JAAOS, and CORR in 1997

The total amount of women first and last authors represented in all three journals increased from 88 of 1450 (6%) in 1997 to 152 of 1912 (8%) in 2007 and to 723 of 5391 (13%) in 2017 (Fig. 1). Similarly, three of 113 (3%) editorial board members were women in 1997, while three of 105 (3%) and 10 of 107 (9%) editors were women in 2007 and 2017, respectively (Fig. 1). Of note, zero out of nine editors-in-chief were women.

Fig. 1.

This figure shows that the percentage of women authors, including both first and last authors, correlated with an increased percentage of women editors in the years 1997, 2007, and 2017.

Discussion

Although women represent slightly more than half of medical school graduates in the United States, there remains a disproportionate representation of women in orthopaedic surgery residency programs and as active practicing orthopaedic surgeons. Our goal was to assess if this discrepancy extends to editorial board membership and authorship in orthopaedic literature. We specifically evaluated the current percent of female first and last authors and editorial board members of three of the most widely read orthopaedic journals: JBJS, JAAOS, and CORR. We then further analyzed how author and editorial board member gender composition has changed between the years 1997, 2007, and 2017. Overall, the total amount of women first and last authors increased from 88 of 1450 (6%) in 1997 to 152 of 1912 (8%) in 2007 and to 723 of 5391 (13%) in 2017. During this same period, the distribution of female editorial board members ranged from three of 113 (3%) to three of 105 (3%) to 10 of 107 (9%).

There are several limitations to this study. Degrees and affiliations of editors and authors were inconsistently provided by journals, so we cannot ensure that all contributors were, in fact, active orthopaedic surgeons or residents. Some of the editors may be biomedical engineers, statisticians, radiologists, or physical medicine and rehabilitation specialists, while some of the authors may be basic science investigators, medical students, or nonorthopaedic physicians. As the percentages among nonorthopaedic contributors may differ by gender, we may over- or underestimate a possible disparity. We initially searched several hundred individual contributors and less than 5% were nonorthopaedic contributors. As there were more than 9000 contributors included in this study, we decided against individually searching each person. An additional limitation is that an editor or author in 1997 may also have contributed in 2007 or 2017. Therefore, we assessed the number of positions occupied by women, rather than the number of individual women occupying the total number of positions.

To determine how women orthopaedic surgeons are represented in orthopaedic journals compared with men, we analyzed the number of women on the editorial boards as well as those who were the first and last authors of research appearing in JBJS, JAAOS, and CORR. In 2017, 12% of authors and 6% of editors in JBJS, 12% of authors and 9% of editors in JAAOS, and 14% of authors and 13% of editors in CORR were women (first and last authors were combined for simplicity). When all three journals were analyzed as a single entity, 13% of first and last authors and 9% of editors were women in 2017. According to the AAMC Physician Specialty Data Report, in 2017, 1016 of 18,997 (5%) of active orthopaedic surgeons and 586 of 3826 (15%) of orthopaedic residents were women [2]. Although most journal contributors are men, the representation of women in journals and editorial boards is possibly greater than the proportion of women in orthopaedics as a whole. This could in part be due to a greater percentage of women who enter orthopaedics choosing academic positions [4].

In light of relatively new efforts to recruit women to the field of orthopaedic surgery, we wanted our analysis to be longitudinal. Therefore, we assessed how the gender proportions of journal authors and editors changed over the past two decades. The total amount of women first and last authors increased from 6% to 8% to 13% in 1997, 2007, and 2017, respectively. During this same period, the distribution of women editorial board members remained static in the first decade (3% in both 1997 and 2007), but increased in the second decade (9%). The AAMC reports that from 2007 to 2017 the number of women orthopaedic surgeons increased from 720 of 20,028 (4%) to 1016 of 18,997 (5%), while the number of female orthopaedic residents increased from 398 of 3201 (12%) to 586 of 3826 (15.3%) [1-3]. Data from 1997 are not available. The proportion of women journal contributors appears to have increased since 1997, paralleling the increase of women in the field. Interestingly, our data show that none of the journals evaluated has a woman serve as editor-in-chief. In fact, most women serve as junior associate editors rather than deputy editors. This may potentially be due to a large proportion of women orthopaedic surgeons who are early in their careers and who may not yet have risen to more senior editorial board positions [4].

In conclusion, our data exhibit that the representation of women in orthopaedic journals meets or exceeds that in the general orthopaedic community. That is, women are as likely as, if not more likely, than men to serve as editors or authors. However, fewer women currently serve in senior roles within the editorial boards. This pattern suggests difficulty in recruiting women into orthopaedic surgery in the first place, rather than existing barriers to women already in the field. Numerous possible detracting factors have been cited as explanations for the lack of women in orthopaedic surgery. Other than income disparities, most of these possible explanations address barriers at the medical student to residency recruitment stage. Elucidation of disparities internally within the field is equally as important. Our study demonstrates that editorship and authorship opportunities are available, regardless of gender, to those seeking them. It is the hope of the authors that this analysis will encourage female medical students considering a career in orthopaedic surgery. Future research should continue to explore how to best recruit women into the field and to overcome any negative perceptions that may hinder attracting outstanding candidates. Further studies are also warranted to assess whether additional leadership positions and resources are as equally available as editorship and authorship are to women orthopaedic surgeons.