Editor’s Spotlight/Take 5: How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?

Racial and gender diversity in the physician workforce is associated with increased patient participation in decision-making [7], greater cultural competency on the part of care teams [14], and more-favorable patient perceptions about medical encounters [15]. For these reasons and others, leading professional organizations in orthopaedic surgery have sought to increase the proportion of women and people of color in our specialty [3, 4] and in the leadership of those organizations themselves [2, 5].

And yet, no specialty is worse than ours in terms of gender balance [6]. We fare similarly poorly on racial diversity. Only 1.9% of practicing orthopaedic surgeons in the United States are Black [7], which represents a nearly tenfold discrepancy with respect to population proportions [12]. And these conversations have been going on for a long time—certainly they predate my time in this specialty, as I recall talking about gender discrimination as a fourth-year medical student during a residency-selection interview in the early 1990s [11].

Inequality of opportunity should be on our minds, of course, but as physicians, we must concern ourselves first with care quality. And the evidence base on gender and racial disparities in care is vast and—for want of a better term—fairly disgusting. Last year, for example, a study published here found that after controlling for all reasonable confounding variables, Black patients with hip fractures sat much longer waiting for care in emergency departments than did white patients [1]. If only that were an isolated story. It’s not.

We’re past needing to describe or define the scope of the problem. For that reason, it’s exciting to Spotlight a study in this month’s Clinical Orthopaedics and Related Research® that offers a solution [13]. This study also gives us reason to believe that the historical stereotypes about our specialty—locker rooms and knuckle draggers, men drawn from the club-and-drag school of dating, minorities need not apply—may be abating.

A group led by Dawn LaPorte MD from Johns Hopkins University in Baltimore, MD, USA, found that medical students from 27 schools across the United States who simply completed an orthopaedic surgery rotation left that experience feeling the specialty was more welcoming to women, people of various sexual orientations, and nonwhite applicants than they believed when they began [13]. Dr. LaPorte’s team looked at these parameters from numerous angles, and the findings were fairly consistent across the board: Spending time with orthopaedic surgeons leaves students feeling that perhaps we’re not so bad after all. Dr. LaPorte’s findings give some hope in terms of perhaps our being able to attract a more-racially diverse pool of applicants, if only we can get more medical students to visit with us.

Dawn LaPorte MD

The trick, of course, will be to get more—and more-diverse—medical students rotating on orthopaedic surgery services. This raises key questions regarding where the responsibility lies for solving a problem that affects the care of the patients we are charged with treating. All of them.

Join me in the Take 5 interview that follows with Dawn LaPorte MD, senior author of “How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?” for some promising, new, real-world practical solutions to problems that have been with us, quite literally, since the birth of our specialty.

Take 5 Interview with Dawn LaPorte MD, senior author of “How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?”

Seth S. Leopold MD: Congratulations on this paradigm-shifting study. You found that if only more women, people of nonstraight sexual orientation, and individuals from racial minority groups were to take orthopaedic rotations in medical school, we’d lower several important barriers keeping our specialty from representing the populations it serves. But we don’t get to determine which medical students take orthopaedic surgery rotations, and most students don’t take them. I wonder whether medical school deans might look at your work and say, “Interesting suggestion, but problems of sexism and discrimination in your specialty are your specialty’s problems to solve, not ours.” Who are the stakeholders here, and how can we get them to engage with your important discoveries?

Dawn LaPorte MD: Medical schools absolutely are stakeholders in this issue. As we point out in the article, one of the missions of the American Association of Medical Colleges is that “Medical schools and teaching hospitals are committed to developing a culturally competent, diverse, and well-prepared health care workforce.” Furthermore, we know that a more diverse and representative physician workforce leads to better overall patient care [8, 14, 15]. Everyone in medicine, and especially those tasked with training the next generation, should feel an obligation to improve diversity in all parts of medicine, not only for the sake of our future doctors, but for our patients. In our study, we identify a specific aspect of medical education that may help improve diversity and we offer some potential solutions. Of course, this does not mean that the problem is solely that of medical schools. The specialty has a responsibility as well. When targeting diversity through medical education, we need to collaborate with our institutions and existing educational infrastructures. The specialty can also consider other creative means of encouraging students to explore the field.

Dr. Leopold: What have you done locally with your findings? In your paper [13], you mentioned doing some case-based teaching in the first year of medical school because orthopaedics is not required during the clinical years. How are your findings being received at Johns Hopkins? Any movement in the curriculum there based on the ray of hope your study offers?

Dr. LaPorte: While we are fortunate to have nearly 20% of students rotate with our orthopaedic services through electives during the clinical years of medical school, it is not a requirement and we wanted to introduce the specialty early on. Six years ago, we began a yearly program in which faculty and residents from the department walk first-year medical students in the anatomy lab through basic orthopaedic procedures on cadavers. We cover procedures like fasciotomies and basic ankle fracture and wrist fracture internal fixation. We think this has been an exciting way for students to gain exposure to more hands-on learning to see what orthopaedics is all about. In addition, we are fortunate to have a diverse department, and it is great for students to see that early as well. At last year’s session, one of the students even shared with us that before the session she had not considered orthopaedic surgery given her perceptions of the demographics of the field. Afterward, she was eager to explore it further because she saw people who looked like her teaching the session. I think this program has been well received at Johns Hopkins, but there is always room for more. Especially now with our study’s findings on the importance of exposure through a clinical rotation, we hope that such opportunities grow for students. At my institution, orthopaedic surgery is offered as an elective during the core surgery clerkship or independently. While I would love to see it incorporated in some way as a required clinical activity, this is easier said than done. We are exploring and promoting ways to embed even a short required clinical exposure for all students as well as incorporating more opportunities for shadowing, possibly in the preclinical musculoskeletal blocks.

Dr. Leopold: And what happens if they don’t take the bait (either locally there or more broadly)? Whose responsibility is it to work on this problem, and what moves would you recommend they make?

Dr. LaPorte: We need to take diversity and inclusion in the field, and strategies for improvement, seriously. The numbers tell us that much of the “drop-off” happens in medical school. Considering gender diversity as an example, more than half of medical school students are women, but women represent only 14% of orthopaedic residents [9]. Clearly, we as a specialty are missing out on some great talent. Medical schools have a responsibility to promote a diverse physician workforce, and that includes within specialties. Given the findings of our study and the benefits of a clinical rotation, medical schools should offer some way for medical students to have required exposure to orthopaedic surgery, and not only to the core clinical requirements. If orthopaedic clinical electives are not offered, they should be. Even if they are offered as an elective, at least short clinical exposures should be incorporated for all students. If a school is not affiliated with an orthopaedics department, perhaps the administration can look into connecting students with a neighboring department or with physicians in the community. The responsibility, however, does not lie solely with medical schools and the medical education infrastructure. The specialty needs to put a lot of work into this as well, and we are seeing many efforts already. Departments can participate in creative efforts for early exposure for students, like what we did with the anatomy course. Pathway programs and scholarships should elevate diverse students. Departments can support and host Perry Outreach Programs and Nth Dimension students. National organizations, including the Ruth Jackson Orthopaedic Society, the J. Robert Gladden Orthopaedic Society, the American Association of Latino Orthopaedic Surgeons, Black Women Orthopaedic Surgeons, the Perry Initiative, and ideally the American Academy of Orthopaedic Surgeons, can and should dedicate resources to addressing this problem as well, supporting and facilitating clinical exposure to orthopaedics and to diverse orthopaedic surgeons. There is so much room for growth in this area; multiple stakeholders need to be engaged. If we want to continue to improve as a specialty and have a workforce that reflects and represents our patients, we and other key players must take the bait.

Dr. Leopold: Sometimes I think the eye is drawn to p values, but it’s effect sizes that matter. I was struck by two things pertaining to the effect sizes in your study. First, how poorly medical students perceived orthopaedic surgeons before their rotations—lots of 1’s on the 5-point scale. But more concerningly, even though you found that things got better after rotations, they never really got “good.” For example, I don’t think the needle even moved past “3” on the 5-point scale, which doesn’t seem so great to me. How do you see this, and, more importantly, what should we do about it?

Dr. LaPorte: That is a great question. For some of our metrics, opinions were in fact more favorable than not. For example, both before and after a rotation, every demographic group saw orthopaedics as more friendly than they did hostile, and there was still improvement pre- to postrotation for women in this domain. There were other metrics where opinions were not as great. When asked whether orthopaedic surgery is more diverse than homogenous, for every group pre- and postrotation, the average scores were closer to homogenous. Women’s views improved for this metric as well, but as you noted, the postrotation scores for this domain still were not “good.” What this means is that even though the rotation may help in improving many negative perceptions of the level of diversity and inclusion in orthopaedics, the rotation alone will not fix the problem. Another interesting takeaway is that while our study was most focused on nonmajority demographic groups’ perceptions (for example, women, underrepresented racial/ethnic minorities, nonheterosexual), we see that even those who fit into majority demographics (for example, men, white, heterosexual) did not have great perceptions of how diverse and inclusive orthopaedic surgery is before the rotation. Not across all the metrics we looked at, but across many of them. So many students, regardless of demographics, recognized this as a problem. For all we know, even a student who fits the majority demographics may be less excited about pursuing a specialty that he or she perceives as less diverse. To be clear, that is not something our study specifically answered, but it is important to consider. As far as what we should do about this—that is our important challenge moving forward—we need not only to increase exposure orthopaedics but also to increase the diversity in the field. That will not happen overnight, but we need to remain committed and be intentional about pathway programs, mentoring, and changing the demographics in orthopaedics over time. Perceptions should change along with the reality.

Dr. Leopold: As you know, CORR has been the official journal of the Ruth Jackson Orthoapedic Society (which represents women in our specialty) for a long time now, and we’re proud to say we recently became the official journal of the J. Robert Gladden Orthopaedic Society (whose mission is to increase racial diversity in orthopaedic surgery). We’ve published numerous symposia on topics related to diversity and disparities, and we often use the Editorial and Spotlight pages to suggest ways our specialty might improve in these areas. What else should journals do to increase fairness and improve care quality for women and patients from underrepresented minority groups?

Dr. LaPorte: Women and underrepresented authorship of research should be promoted, whether through specific outreach encouraging such work or ensuring nondiscriminatory practices in the evaluation of research studies. Additionally, research, not just in orthopaedics, but overall, often studies populations that are not representative of the diversity in our society. For example, women or minority populations may not always be included as study participants in proportion to their numbers in society [10]. Journals should promote inclusive study populations, especially when evaluating prospective studies. Finally, journals need to support that studying problems of diversity and disparities matters. My coauthors and I are grateful that CORR has taken an interest in our work, and hope that future research in this area continues to be published by CORR and other journals.