Chair Versus Chairman: Does Orthopaedics Use the Gendered Term More Than Other Specialties?

Abstract

Background

Orthopaedics is the least gender-diverse medical specialty. Research suggests that the use of gendered language can contribute to workforce disparity and that gender-neutral language supports the inclusion and advancement of women, but the degree to which gender-neutral language is used by academic departments in what typically is a department’s highest position (department chair) has not been characterized.

Questions/purposes

(1) Is the proportion of department websites that use the term chairman (as opposed to chair) greater in orthopaedics than in five other surgical and medical specialties? (2) Are departments led by chairs who are women less likely to use “chairman” than those led by men, and does this vary by specialty?

Methods

Seven hundred fourteen official websites of orthopaedic, neurosurgery, general surgery, internal medicine, pediatrics, and obstetrics and gynecology departments affiliated with 129 allopathic medical schools were screened. Any use of the term chairman on title pages, welcome messages, and faculty profile pages was identified using a Boyer-Moore string-search algorithm and terms were classified based on their location on the site. The overall use of the term chairman was compared by specialty and gender of the chair.

Results

Sixty percent of orthopaedic department websites (71 of 119) used the term chairman at least once, a proportion higher than that of pediatrics (36% [46 of 128]; OR 0.38; 95% CI, 0.23 to 0.63; p < 0.001), internal medicine (31% [38 of 122]; OR 0.030; 95% CI, 0.18 to 0.53; p < 0.001), and obstetrics and gynecology (29% [37 of 126]; OR 0.28; 95% CI, 0.17 to 0.48; p < 0.001), but no different than that of neurosurgery (57% [54 of 94]; OR 0.91; 95% CI, 0.52 to 1.6; p = 0.74) and general surgery (55% [69 of 125]; OR 0.83; 95% CI, 0.50 to 1.4; p = 0.48). Across disciplines, departments whose chairs were women were much less likely to use the term chairman than departments whose chairs were men (14% [17 of 122] versus 50% [297 of 592]; OR 0.16; 95% CI, 0.09 to 0.28; p < 0.001).

Conclusions

The frequent use of the term chairman in orthopaedics, coupled with the preference of women to use the term chair, suggests considerable room for growth in the use of gender-equal language in orthopaedics.

Clinical Relevance

Our current efforts to increase the number of women in orthopaedics may be undermined by gendered language, which can create and reinforce gendered culture in the field. Electing to use gender-neutral leadership titles, while a relatively small step in the pursuit of a more gender-equal environment, presents an immediate and no-cost way to support a more inclusive culture and counteract unconscious gender bias. Future studies should explore the individual attitudes of chairs regarding the use of gendered titles and identify additional ways in which biases may manifest; for example, the use of gendered language in interpersonal communications and the presence of unconscious bias in leadership evaluations. Continued efforts to understand implicit bias in orthopaedics can guide actionable strategies for counteracting gendered stereotypes of the specialty, in turn aiding initiatives to recruit and promote women in the field.

Introduction

The gender gap in academic medicine is well documented [6]. Despite higher numbers of women medical students, residents, and faculty members than ever before [19], women still struggle to achieve equality in salaries [17], funding [18], and career trajectories [30]. The gap may be even more pronounced in orthopaedics, where men account for more than 90% of the surgical workforce [1]. Despite efforts by training programs to recruit and retain more women, the profession’s rate of gender diversity growth has continued to lag behind that of other medical specialties [28], and women in orthopaedics continue to be underrepresented in high-ranking faculty positions and publication rates [26].

There are many causes of gender disparity, including not only well-known gaps in mentorship and development resources [15], but also more subtle biases and signals that can create and perpetuate gendered stereotypes [12, 25]. Among these are job titles that have historically excluded women [9]. The effect is intuitive; a gender-specific job title reinforces an atmosphere of gender hierarchy by indicating a position is meant for one gender and not the other. This effect has been demonstrated elsewhere—gender-marked job titles such as fireman or stewardess are often perceived, even by young people, as excluding the participation of the other gender [20]. Gendered language has also been shown to contribute to occupational stereotypes, directly affecting how women in professional settings are evaluated [21, 23].

Given the demonstrated impact of exclusionary language in perpetuating gender disparity, we sought to evaluate how gendered titles (as an example of gendered language) are used in orthopaedics compared with other specialties. We also aimed to determine whether women in leadership roles in medicine notice or use these titles any differently than men.

Specifically, we asked, (1) Is the proportion of department websites that use the term chairman (as opposed to chair) greater in orthopaedics than in five other surgical and medical specialties? (2) Are departments led by chairs who are women less likely to use “chairman” than those led by men, and does this vary by specialty?

Materials and Methods

Selection of Departments

The official academic websites of orthopaedic, neurosurgery, general surgery, internal medicine, pediatrics, and obstetrics and gynecology departments from each United States allopathic medical school participating in the American Medical College Application Service were analyzed. Schools in Canada and Puerto Rico were excluded because a non-English language is often spoken in these countries. Only primary academic departments were included; departments with secondary hospital affiliations were not analyzed. The formal titles of individual departments varied but represented one of the six academic disciplines. Departments were categorized by specialty and region (Northeast, South, Midwest, and West) for comparative analyses.

In total, 148 medical schools were identified, of which 87% (129 of 148) had identifiable departmental affiliations and functioning websites. Across these 129 schools, 734 individual department websites in one of the six specified specialties were found. Ninety-seven percent (714 of 734) identified department chairs or interim chairs. All 714 of these websites were screened for chairman use: 119 in orthopaedics, 94 in neurosurgery, 125 in surgery, 122 in internal medicine, 128 in pediatrics, and 126 in obstetrics and gynecology.

Analysis of the Titles Chair and Chairman

The website of each academic department was screened by a single reviewer (CJP). Each website was screened for use of the word chairman on the department home page, residency welcome pages, and the faculty profile page of the chair using a Boyer-Moore string-search algorithm for pattern searching (browser-embedded find function). Any nonofficial internet-based materials such as news articles, LinkedIn profiles, and links to external websites were excluded from analysis.

Use of the term chairman was recorded as a binary yes or no, and any single use of the word chairman was coded as a positive yes for that site. Use of the term on each website was also classified as yes or no in one or more of the following categories: (1) website template—the word chairman was used on website banners or menus; (2) title—the word chairman was used in the official title block of a faculty member’s profile or in a signature block in welcome messages; and (3) descriptive text—use of the word chairman anywhere outside the previous two categories, including text in biographies, department descriptions, and welcome messages. For example, if a website contained the term chairman only once in an embedded side menu, it was recorded as a yes for overall use and yes for website template, but a no for the other two categories. If a website contained three instances of the term chairman—one under the signature of the chair and two in a descriptive paragraph—it was recorded as a yes for signature, descriptive text, and overall use, but a no for website template. Thus, final categorical percentages reflect the proportion of sites containing one or more instances of the term chairman in each specified category.

Statistical Analysis

A regression analysis was performed in STATA version 15.1 (StataCorp LLC; College Station, TX, USA) using linear regression analyses. These models were replicated with logit and probit regression analyses, with qualitatively similar results.

Results

Use of the Term Chairman in Orthopaedic Versus Other Departments

At least one use of the term chairman was identified in 60% of orthopaedic department websites (71 of 119). This use was higher than that of pediatrics (36% [46 of 128]; OR 0.38; 95% CI, 0.23 to 0.63; p < 0.001), internal medicine (31% [38 of 122]; OR 0.30; 95% CI, 0.18 to 0.53; p < 0.001), and obstetrics and gynecology (29% [37 of 126]; OR 0.28; 95% CI, 0.17 to 0.48; p < 0.001), but no different from that of neurosurgery (57% [54 of 94]; OR 0.91; 95% CI, 0.52 to 1.6; p = 0.74) and general surgery (55% [69 of 125]; OR 0.83; 95% CI, 0.50 to 1.4; p = 0.48) (Fig. 1). Across all six specialties, 44% of department websites (314 of 714) used the term chairman.

Fig. 1.

This figure shows use of the term chairman on department websites and the number of women as chairs in orthopaedics compared with other specialties. The symbols * and # indicate statistical difference in relation to orthopaedics (p < 0.01).

The word chairman was more likely to be found in descriptive text (26% [187 of 714]) than in a signature (21% [152 of 714]; OR 1.3; 95% CI, 1.0 to 1.7; p = 0.03) or website template (16% [117 of 714]; OR 1.8; 95% CI, 1.4 to 2.3; p < 0.001). In orthopaedics, 22% of websites (26 of 119) used the word chairman in a website template, 30% (36 of 119) used it in descriptive text, and 29% (34 of 119) used it in signature blocks or as a title.

There were no qualitative differences in findings after controlling for the location of the program and the number of chairs who were women (the location of the program or the presence of more women chairs in a specialty did not account for variation). However, there were differences in title use by region in the United States. Across disciplines, the proportion of departments in the South using the term chairman was no different from that of the Northeast (51% [126 of 246] versus 46% [89 of 192]; OR 1.2; 95% CI, 0.83 to 1.77; p = 0.31), but higher than that of the Midwest (37% [62 of 166]; OR 1.7; 95% CI, 1.18 to 2.63; p = 0.006) and the West (28% [31 of 110]; OR 2.7; 95% CI, 1.6 to 4.3; p < 0.001).

Use of the Term Chairman in Departments with Chairs who are Women

Across disciplines, departments whose chairs were women were less likely to use the term chairman than departments whose chairs were men (14% [17 of 122] versus 50% [297 of 592]; OR 0.16; 95% CI, 0.09 to 0.28; p < 0.001). Use of the term chairman was lower among women in all three categories of website use: as a title or signature (3% [four of 122] versus 25% [146 of 592]; OR 0.10; 95% CI, 0.04 to 0.29; p < 0.001), within a website template (6% [seven of 122] versus 18% [107 of 592]; OR 0.28; 95% CI, 0.13 to 0.61; p = 0.001), and in descriptive text (10% [12 of 122] versus 30% [178 of 592]; OR 0.25; 95% CI, 0.22 to 0.79; p < 0.001) (Fig. 2).

Fig. 2.

This figure shows use of the term chairman on the websites of departments led by women compared with those led by men. The symbol * indicates statistical difference between men and women in each category (p < 0.01).

Across specialties, the websites of departments whose chairs were women rarely used the term chairman: 0% (zero of one) in orthopaedics, 0% (zero of four) in neurosurgery, 10% (six of 59) in obstetrics and gynecology, 11% (four of 35) in pediatrics, 25% (five of 20) in general surgery, and 6% (two of 32) in internal medicine. The websites of orthopaedic departments led by men were as likely to use the term chairman (59% [70 of 118]) as those of neurosurgery departments (56% [53 of 94]; OR 1.1; 95% CI, 0.65 to 2.0; p = 0.67) and surgery departments led by men (60% [64 of 107]; OR 0. 98; 95% CI, 0.57 to 1.7; p = 0.94), but more likely than the websites of internal medicine departments (31% [32 of 103]; OR 3.2; 95% CI, 1.9 to 5.6; p < 0.001), pediatrics (46% [43 of 94]; OR 2.1; 95% CI, 1.2 to 3.5; p = 0.008], and obstetrics and gynecology departments led by men (40% [32 of 80]; OR 2.2; 95% CI, 1.2 to 3.9; p = 0.008).

Overall, only 18% (127 of 714) of academic department chairs were women. The proportion of women as chairs in orthopaedics (1% [one of 119]) was no different than that of neurosurgery (4% [four of 94]; OR 0.20; 95% CI, 0.02 to 1.7; p = 0.14), but lower than that of surgery (16% [20 of 125]; OR 0.04; 95% CI, 0.01 to 0.33; p = 0.003), internal medicine (20% [24 of 122]; OR 0.03; 95% CI, 0.00 to 0.26; p = 0.001), pediatrics (27% [35 of 128]; OR 0.02; 95% CI, 0.00 to 0.17; p < 0.001), and obstetrics and gynecology (47% [59 of 126]; OR 0.01; 95% CI, 0.00 to 0.07; p < 0.001) (Fig. 1).

Discussion

Research in other fields has demonstrated the detrimental impact of gendered language on workplace environment and inclusivity [13, 14], with surgical specialties being especially prone to gender-related discrimination [2, 5]. Given the marked gender imbalance and perceived gender biases in orthopaedics [7], this study sought to critically examine the use of gender-exclusive titles, which may play a role in perpetuating the field’s gender gap. We found orthopaedics, neurosurgery, and general surgery department websites use the term chairman much more frequently than department websites of obstetrics and gynecology, pediatrics, and internal medicine. We also found an independent relationship between leader gender and job title. The websites of women who are chairs use the gendered title chairman much less than those led by men. This understanding of potential language-rooted biases in the field, however subtle, can guide simple yet useful changes for increased workplace inclusivity; in this case, electing to use the term chair instead of chairman.

There are limitations inherent to this study’s design. The analyzed websites, while used as a proxy for departmental culture, may not fully represent institutional practices, because the involvement of faculty members with their websites varies. However, our findings, particularly the nearly absent use of the term chairman on websites of departments led by women, show that titles, while undoubtedly not an exhaustive representation of gendered language, are also not arbitrary. We attempted to account for some of this variation by classifying the term chairman by its location on the website (such as a website template and formal signature block). The methodology of this study is also insufficient to prove a cause-and-effect relationship between gendered titles and gender disparity and does not demonstrate whether or how the influence of gendered titles varies across contexts. Whereas a child reading the words fireman or stewardess might strongly associate specific genders with those job titles, mid- or late-career women in orthopaedics may not perceive the term chairman as indicating a position solely for men. Nonetheless, the frequent use of gendered titles in orthopaedics may indicate more pervasive gender biases that, collectively, have a detrimental impact on women in the profession. In addition to inadvertently undermining the leadership pursuits of women [10, 12, 13, 16, 22], gender titles and other related biases can both implicitly and explicitly dissuade women from entering the specialty [2, 4, 7, 23, 24]. Given these limitations, the findings of our study do not indicate gender-neutral titles are the cure-all solution for gender disparity or unconscious bias in the profession but point to them as an immediate area for improvement to counteract a broader gendered culture. Our findings suggest that the selection of titles, while subtle, is neither random nor inconsequential.

Primarily, we found higher proportions of the use of the term chairman in surgical specialties with historically higher numbers of men (orthopaedics, neurosurgery, and general surgery). The use of chairman in these specialties may be a form of broader linguistic patterns that can create and perpetuate gendered stereotypes in surgery. These, in turn, can explicitly and implicitly dissuade women from entering the field and contribute to a gender-exclusionary environment for those in it [16]. When used in job descriptions, traditionally masculine language—prevalent in surgical practice—has been shown to implicitly deter women from applying to those jobs, as well as decrease their chances of being hired [3, 10, 16]. In orthopaedics specifically, the well-known “jock and fraternity” stereotype has been cited as a factor turning women away from the field during medical school, even in the presence of proactive efforts by orthopaedic departments to recruit more women [4, 22, 24]. Surely, there are principles in these stereotypes—camaraderie and athleticism, for example—that are universally attractive to people of any gender. An important linguistic difference, however, between the terms and the jock and fraternity stereotype is that the latter refers to the attributes applied in gender-exclusive environments. Far from dismissing the unique qualities of surgery, electing to use gender-equal descriptors could place a greater emphasis on work skills, rather than the work skills as applied by men. Use of the word chair instead of chairman may be an example of how gendered connotation can be eliminated without any sacrifice of meaning.

Our study also found that departments led by women were substantially less likely to use the term chairman than departments led by men. This further signals the exclusionary nature of the term, as it suggests that the choice of chair by women, however subtle, was deliberate. This finding is not surprising. Gendered narratives and linguistic tropes have been shown to reduce feelings of belongingness and identification in the workplace and decrease career motivation [31]. They have also been shown to negatively affect work evaluations for women in fields dominated by men [23]. Women applicants are perceived to be less qualified than men for high-status positions when a masculine title is used but are judged similarly when word pairs (for example, businessman and businesswoman) are used [16]. Although each chair’s motivations for using the term chair or chairman may be different, our data suggest that the choice is not arbitrary. The previously cited studies also show that the choice is important.

The preference of women to use the term chair may also further explain why the alternative, chairman, was used more frequently in fields with higher percentages of men. Historically, women have been the drivers of gender-equal change in medicine [27]. Thus, having more colleagues who are women (whether they are serving as a departmental chair) may help facilitate cultural and linguistic change. This may be why internal medicine, in contrast to the other five specialties, had a relatively low proportion of chairman use, even though most chairs were still men. The percentage of women in internal medicine (37% of practicing physicians), while a minority, is still much greater than that in orthopaedics (5%), neurosurgery (8%), and general surgery (19%) [1]. This may also explain why general surgery websites used the term chairman more frequently than internal medicine websites, despite having a similar number of women as chairs. Notably, the relative success of general surgery in hiring women as chairs (compared with orthopaedics and neurosurgery) despite continued chairman use highlights the fact that there are numerous ways to promote women in leadership. However, importantly, women in general surgery still used the term chairman much less frequently than men. The persistence of the term chairman despite leadership changes reinforces the notion that unconscious bias may be especially prevalent in traditionally male surgical settings. In orthopaedics, with a particularly low number of women chairs and high use of the term chairman, it may be especially important to be cognizant of and address these biases, in addition to pursuing other important avenues for the promotion of women in the field.

Taken together, our findings suggest substantial room for improvement in the use of gender-equal titles in orthopaedics and the other studied specialties, where gender issues are also a concern [8, 14]. Although electing to use a gender-neutral title, by itself, will not resolve all of these concerns, one study has shown that individuals merely exposed to gender-equal language are more likely to use it themselves [11]. Thus, even a simple change in title can contribute to cultural change, aiding continued gender-equal initiatives in the field. This pursuit of gender equity should be considered a top priority, as it has been called “one of the most important drivers of health and health inequalities of our time” [29]. In this light, we recommend all physicians pursue areas for growth toward a more gender-equitable future, including small linguistic changes such as replacing the word chairman with the word chair.

Conclusion

Our study demonstrates more frequent use of the gendered word chairman as a title of leadership on department websites in orthopaedics, neurosurgery, and general surgery than in internal medicine, pediatrics, and obstetrics and gynecology, and shows that women chairs prefer to use the title chair. Given the especially large gender gap in orthopaedics and the potential of gender-equal language to stimulate cultural change, departments should strive to use gender-equal language where possible, including replacing the term chairman with chair. Although changes in nomenclature may be a comparatively small step in the pursuit of gender equality, they are also a simple, immediate, and costless way to reflect and support a culture that values women in leadership. Future studies should explore the individual attitudes of chairs regarding the use of gendered language and identify ways in which leadership biases may influence career opportunities for women and other minorities in the profession. Because the high use of chairman in orthopaedics may indicate a broader gendered culture in the specialty, studies might also examine additional forms of implicit bias and their effects on women at various points along the career path. Together, these studies can guide actionable strategies for counteracting gender biases in orthopaedics, aiding efforts to improve the recruitment and advancement of women in the field.