CORR Insights®: What is the Geographic Distribution of Women Orthopaedic Surgeons Throughout the United States?

Where Are We Now?

It is estimated that by 2050, there will no longer be any clear racial and ethnic majority in the United States. Indeed, Americans of Hispanic and Asian descent comprise of the fastest-growing population segments [5]. As the US population becomes more diverse, the need for diversity and multi-culturalism in medicine will become ever-more essential. The characteristics of many clinical encounters today, including time pressure, cognitive complexity, and cost-containment measures, increase the likelihood of care poorly matched to minority patients’ needs [14]. Additionally, minority patients may experience a range of other obstacles to accessing care, including barriers of language, geography, and cultural familiarity [14]. In addition to race and gender, workplace diversity includes variation in age, ethnicity, physical attributes, educational background, sexual orientation, geographical location, socioeconomic status, marital and parental status, spiritual practice, and previous work experience. Any organization’s growth and success depend upon its ability to understand and effectively meet the needs of an increasingly diverse customer-patient population. Diverse organizations also benefit from enhanced: (1) Adaptability to fluctuating conditions and patient demands, (2) skillsets and competencies extending the range of potential customers-patients, and (3) idea pools and innovative solutions [6, 7, 19].

The Council on Graduate Medical Education first expressed concern about the growing disparity between the physician specialty and geographic maldistribution in 1988, despite an increasing aggregate supply of physicians within the United States. It found that “the composition of the Nation’s physicians [did] not reflect the general population” contributing to a “crisis in health care delivery” [9]. In 2011, the Association of American Medical Colleges (AAMC) reported a continued maldistribution of physicians by specialty and geography [1].

Men far outnumber women in nearly all surgical subspecialties, and surgeons of color are under-represented across the board in medicine—a disparity that is even more severe in surgery [11, 12]. This is problematic for many reasons, not least of which is that patient-physician race-concordance has been demonstrated to have higher patient satisfaction ratings; the same has been shown for patient-physician gender concordance [22].

Definite signs of progress are visible in medical schools and in some subspecialties during residency for women and under-represented minorities. For instance, women have increased from 48% to 51% of medical school matriculants since 2002. Women also account for the majority of graduate medical education trainees in obstetrics and gynecology, pediatrics, dermatology, internal medicine/pediatrics, family medicine, pathology, and psychiatry [2, 12]. Moreover, from 1995 to 2010, the percentage of women faculty members in orthopaedic departments has nearly doubled (from 4.9% to 8.1%), as did black (3.6% to 5.4%), Asian/Pacific Islander (6.6% to 11.8%) and women orthopaedic residents (6.1% to 14.5%) [10].

However, radiology, orthopaedic surgery, and otolaryngology still stand out as specialties with poor representation for black and Hispanic women trainees; orthopaedic surgery has the lowest percentage of women trainees at ∼ 14% [12]. Saliently, in the current study, Chapman and colleagues [8] demonstrate that the gains seen in the numbers of women in orthopaedics are distributed unequally across the United States. This is important because the goal of diversity efforts in medicine, orthopaedics in particular, is to increase the cultural/racial/gender concordance between patient and physician. Thus, physician representation must mirror the local patient population - without simultaneous improvements in geographic distribution, disparities in access to women orthopedists remain based on geographic location.

Where Do We Need To Go?

Orthopaedics strives to be more diverse, but our approaches for reaching that goal remain controversial. There is a notion that the specialty should be representative of the patient-population it serves. Women represent about half of the general US population and about half of medical school matriculants, therefore, one could argue that the proportion of women orthopaedic surgeons likewise should be about 50%. However, achieving this end goal depends on having a large enough pool of women applying to orthopaedic surgery residency positions to fill this need. There is no question that orthopaedic surgery is a competitive specialty overall. Thanks to a surplus of qualified applicants, orthopaedic residency programs overall have essentially become a “buyer’s market” [23]. According to the 2019 National Resident Matching Program report, there were 1037 total applicants (830 US graduates) for a total of 755 PGY-1 orthopedic surgery positions offered by 175 programs, of which 752 PGY-1 positions filled for a 99.6% fill rate [18]. However, from 2005 to 2014, female applicants to orthopaedic residency positions increased from about 13% to 16%, corresponding with the percentage of enrolled female residents (from about 13% to 16%) [20]. Since the acceptance rates for residency positions are proportional to (or representative of) the number of applicants, there is evidence to support that a root cause of the lack of diversity in orthopaedics is a lack of diversity in the applicant pool for our residency programs.

We need to systematically encourage qualified candidates from the under-represented groups to apply for orthopaedic residency programs. Convincing 50% of the women in medical school to apply for orthopaedic surgery will have significant challenges. Biological imperatives dictate that women will need some recuperative time following childbirth, and social conventions remain that women take more time for parental leave versus men. Time away from work is hard on surgeons, especially surgeons-in-training, and so perhaps the demands of a surgical specialty may make it less attractive to women. We need to address this perceived pregnancy bias in surgical specialties to recruit more women. Identified barriers include lack of uniformity in surgical residency policies regarding parental leave, inflexible work demands during late stage pregnancy, inconsistent access to childcare, lack of adequate lactation facilities, and lack of mentorship on career-family balancing [17, 21]. Finally, it is possible that the stereotype of orthopaedics—as just a “mechanically oriented” specialty—discourages women from pursuing the specialty [13].

How Do We Get There?

Data support the efficacy of employing certain strategies for increasing physician workforce diversity, including: (1) Early exposure to specialty fields; (2) addressing educational gaps; (3) mentoring; (4) the presence of and interaction with faculty reflective of women and under-represented minority groups; and (5) the development of an institutional culture or network that is supportive of women and minority physicians [3].

The process of applying to orthopaedic surgery residency is a complex, competitive experience and many women applicants reportedly eliminate programs from consideration based on perceived gender bias [23]. Bohl and colleagues [4] reported that 61.7% of women who are orthopaedic surgeons reported being asked an inappropriate question during residency interviews. The most common themes of questions included “raising children during residency” (37.9%), “marital status” (32.4%), and “pregnancy during residency” (29.7%). Thus, department chairs and program directors may want to consider incorporating strategies to minimize unconscious bias during the interview process. These steps may include incorporating unconscious-bias education into their faculty development curriculum, adding structured standardized questions to ask each candidate, using strictly gender-neutral questions during the interview process, and adopting pre-defined evaluation criteria prior to actually meeting the candidates [15].

The perceived culture of orthopaedic surgery training is cited as being unwelcoming to women [16]. Unfortunately, this does allow other surgical specialties (nearly all of which are also mostly men) to outpace orthopaedics in attracting women residents as a proportion of trainees in those specialties (Table 1). The most-obvious difference between us and our general surgery colleagues, is that general surgery is a required, mandatory clerkship for all medical students early in the undergraduate medical education process. Orthopaedic surgery, on the other hand, is an elective rotation for those who have already identified orthopaedics as a potential career choice. Thus, by the time orthopaedic faculty have initial contact with a prospective candidate, our general surgery colleagues have already applied three of the strategies outlined by Auseon and colleagues [3] to all of the medical students—early exposure to specialty fields, addressing educational gaps, and opportunity to mentor prospective candidates.

Table 1.

Surgical specialties that outpace orthopaedics in recruiting women residents 2

Many factors make a specialty desirable to potential candidates. While a goal of women comprising 50% of graduating orthopaedic surgeons may be a stretch, it is conceivable that we can achieve gender parity with the other surgical specialties. Through deliberate and consistent employment of the strategies outlined, I believe we can—and must—achieve gender parity with the other surgical subspecialties