Gender Diversity in Orthopedic Surgery: We All Know It’s Lacking, but Why?

Abstract

Background:

15% of orthopedic surgery trainees in 2018-2019 in ACGME accredited programs are female, which lags behind all other specialties.

Methods:

The bottleneck for achieving gender diversity in orthopedic surgery is that female medical students do not choose orthopedic surgery as a career. In 2018-2019, twelve ACGME accredited programs had no women trainees, highlighting the uneven distribution of female trainees across residency programs. Social science has outlined that 30% representation within a population is the diversity goal.

Conclusion:

A goal of having females comprise 30% of orthopedic surgeons trainees can be achieved with: pipeline programs such as the Perry Initiative and Nth Dimensions; increased orthopedic surgery rotation clinical experience during medical school; and mentorship that promotes and encourages gender diversity. Additionally, recognizing implicit bias as well as explicit discrimination, harassment, and bullying, creates a workplace environment that is inclusive and safe for employees, trainees and physicians, as well as the patients that we serve.

Level of Evidence: V

Introduction

Defining the Problem

The pipeline for training orthopedic surgeons is filled with women. 57% of undergraduate students in the United States are female; 51% of medical students are women. Nevertheless, only 15% of orthopedic residents are women.

As shown in Table 1, at 15.4% in 2018-2019, orthopedic surgery has the smallest percentage of female residents of the top 10 specialties by size of residency.¹

Table 1.

Top Ten Specialties By Size

Specialty	Number of Residency Positions	Percentage of All Residency Positions	Number of Female Residents	Precentage of Residents Female
Internal Medicine	27,179	20	11,474	42
Family Medicine	12,441	9	6,670	54
Surgery, General	9,303	7	3,839	41
Pediatrics	8,950	7	6,449	72
Emergency Medicine	7,681	6	2,722	35
Anesthesiology	6,141	5	2,065	34
Psychiatry	6,014	4	2,999	50
Obstetrics / Gyn	5,453	4	4,550	83
Radiology	4,362	3	1,171	27
Orthopedic Surgery	4,021	3	619	15

In examining the composition of residents training in surgical subspecialties, orthopedic surgery is training the lowest percentage of women, falling behind neurosurgery, urology, plastic surgery, general surgery, and colorectal surgery.¹

As a profession, we cannot state that we recruit and accept the best and brightest medical students to the practice of orthopedic surgery as a career, if we continue to fail to attract and accept more women into our ranks. Adding diversity to an organization provides more diverse perspectives for effective decision-making, greater innovation and creativity for organizations, as well as greater understanding of the population that we treat.² Diversity expands the talent pool and can strengthen our profession.

The goal of this paper is to outline steps that need to be taken in order to improve gender diversity within orthopedic surgery.

Methods

Obstacles to Achieving Gender Diversity in Orthopedic Surgery

The bottleneck for achieving gender diversity in orthopedic surgery is that female medical students do no choose orthopedic surgery as a career. In fact, women medical students choose orthopedic surgery as a significantly lower rate than any other medical or surgical career, as demonstrated in Tables 1 and 2. Significant research has been done examining the question: why do female medical students not choose orthopedic surgery for residency training?

Figure 1.

GME track data 2018-2019.

Table 2.

Surgical Subspecialty Female Resident Representation

Surgical Specialty	Percentage of Female Trainees
Colorectal Surgery	42.7%
General Surgery	41.3%
Plastic Surgery	30.5%
Urology	25.8%
Neurosurgery	17.5%
Orthopedic Surgery	15.4%

The most common reason medical students choose a specialty is experiences during medical school.³ In many medical schools, musculoskeletal medicine is poorly represented in the curriculum and is not a required clinical rotation. Studies have proven that a required third-year rotation exposes more medical students to orthopedics and increases the diversity of matching students.⁴ Female medical students have also indicated that they more commonly are influenced by clinical rotations (85%) and faculty mentors (55%) than are male medical students (56%, 37% respectively). ³

Musculoskeletal curriculum in medical schools generally is poorly represented. Additionally, the presence of enthusiastic orthopedic surgery role models in medical school are significantly more important for female medical students. Because female medical students rely heavily on faculty role models, the importance of enthusiastic and encouraging role models in orthopedic surgery cannot be overstated.⁵

A non-inclusive work environment in orthopedic surgery is another reason that female medical students may not choose orthopedic surgery. In a recent survey of members of the AAOS, 81% of females who responded to the survey had experienced discrimination, bullying, sexual harassment, or harassment with definitions as shown in Table 3.⁶

Table 3.

Definitions from Royal Australasian College of Surgeons

Discrimination	Treating a person with an identified attribute or personal characteristic less favorably than a person who does not have that attribute or characteristic
Bullying	A behavior or pattern of behaviors that a reasonable person would expect might victimize, humiliate, undermine or threaten a person to whom the behavior is directed
Sexual Harrassment	Unwelcome sexual advances, request for sexual favors and other unwelcome conduct of a sexual nature by which a reasonable person would be offended, humiliated or intimidated
Harrassment	An unwanted, or unwelcome or uninvited behavior that makes a person feel humiliated, intimidated or offended

This AAOS workplace culture survey found that 66% of respondents have experience such behaviors including all age groups, racial groups, and genders. In a hierarchical surgical social structure, significant power differential exists between individuals, which can be abused to create a negative work culture. Similar to these AAOS Survey findings, the Royal Australasian College of Surgeons found that 49% of its responding members had experienced discrimination, bullying, sexual harassment, and harassment behaviors in the workplace.⁷ The most common individuals displaying harassing behaviors were attending surgeons, but also fellow trainees, non-surgical attending‘s, nursing staff and administrators. It would be reasonable to extrapolate that negative workplace behaviors in a culture that supports these behaviors are barriers to entry into the field of orthopedic surgery particularly for women. Changing the workplace culture to be inclusive and equitable with a safe work environment for all of the orthopedic surgeons, both in training and in practice, is an important goal for our profession.

Importance of Workplace Culture

An inclusive workplace culture values people. Diversity in leadership styles with a caring safe and respectful culture embraces and inclusive workplace and provides a more effective and innovative organization for all. Diversity within the organization is also important because organizations include not only physicians but also the ancillary personnel, residents, medical students, employees, as well as patients that we serve. The workplace culture embraces all aspects of the physician patient encounter and improves patient care by valuing diversity inclusion and equity for all.

Unconscious bias also affects patient care. For example, a Canadian study with a standardized male and female patients with moderate knee osteoarthritis reported that the odds of a family practice physician recommending a total knee arthroplasty to a male patient was twice that of a female patient. They also reported that the odds of an orthopedic surgeon recommending total knee arthroplasty to a male patient was 22 times that of a female patient.⁸ Diversifying our workforce helps reflect the population that we serve and the care that we deliver, to help address healthcare discrepancies.

30% Rule As Diversity Goal

In a culture where a woman is the only female surgeon in a sea of male sugeons is a culture where the female is placed in a position of being the token. As a token female, her point-of-view can be construed to represent “the women’s” point-of-view, and her performance can be construed to represent the performance of all women. In that way, the introduction of females into the orthopedic workplace has required resilience, grit, and toughness for the pioneering women. As a token woman, “Whatever women do, they must do twice as well as men to be thought half as good” (Mayor Charlotte Whitten 1951).

Overtime, the next step in the evolution of gender diversity is to “tick the box” by having two women representatives. “On board of directors, many have worked hard to recruit two women, then efforts appear to have declined presumably because they hit a level of diversity they seen satisfactory” (Washington post November 3, 2018)

Social science has outlined that 30% representation within a population is the diversity goal.⁹ At 30% of the population, the critical mass has been reached so that the under-represented population becomes incorporated and represented in the institutional culture.¹⁰ One example of this phenomenon was seen in the following setting. In an insurance company with eight separate offices, a diversity initiative was launched, with one female hired into each group. Within one year, nearly all females had quit. This diversity initiative was re-examined. Rather than putting one female in each insurance unit, four females were hired into select units. With the structure of 30 to 50% females in each of the select units, an inclusive culture was created, and the female insurance hires succeeded. Changes to the institutional culture to be accepting of a diverse population is key to incorporating that underrepresented population. This defines the goal of 30% critical mass.¹¹

Distribution of Females in Residency Programs

According to the social science data presented above, an analysis of the distribution of female residents within training programs in the United States can help shed light on some of the challenges that exist.

GME track is a national database that records the demographics of all residents training in ACGME accredited programs. The 2018-19 GME track data (Figure 1) shows that of the 179 orthopedic surgery residency programs, 12 programs had no women residents. Additionally, 33/179 (18%) have only one woman. For medical students that are rotating at programs with zero or one woman, difficulties of an inclusive and accepting workplace may arise.¹²

The number of females training in orthopedic surgery is increasing over time. For the academic year of 2004-2005, the percent of females in ACGME accredited residency programs was 7.8%; for 2018-2019, this has now improved to 15.4%. In 2004- 2005, the number of programs with greater than 20% women was 47/145 (32%), which in 2018- 2019, is now improved to 102/179 programs (57%).^13,14

Discussion

If our goal is to have females comprise 30% of orthopedic surgeon trainees, at the present rate of “improvement”, this will be achieved in 2072. How could we achieve this goal more quickly? Research has shown that pipeline programs such as the Perry Initiative and Nth Dimensions are effective in recruiting female medical students into the profession of orthopedic surgery.^15-17 Additionally, the importance of the orthopedic rotation clinical experience and requiring a musculoskeletal experience is necessary.¹⁸ Providing mentorship that promotes and encourages gender diversity can increase medical student interest in orthopedic surgery. Most importantly, recognizing implicit bias as well as explicit discrimination, harassment, and bullying, can create a workplace environment that is inclusive and safe for employees, trainees and physicians, as well as the patients that we serve.

Conclusion

In conclusion, gender diversity is needed to increase in orthopedic surgery. Female surgeons help provide culturally competent care and can help address healthcare disparities.^19,20 Gender diversity can be achieved. If each medical school in the United States attracts one additional female medical student to choose orthopedic surgery, this would provide 30% female representation in orthopedic surgery residency programs within two years. After 30% is achieved, gender diversity can be self-sustaining. If programs that help increase the medical student interest, such as Perry Initiative and Nth Dimensions, were available at every United States medical school, we could achieve this diversity goal. Additionally, an improved workplace culture that grounds its selection and promotion on competency based data, rather than outdated “old boys club” values, will create a safe environment that values inclusion and equity.