Editor’s Spotlight/Take 5: How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry

Give us some time. We’re working on the problem. I’ve got my best guy on it.

If you’ve ever owned a home, run a business, or purchased a consumer product, you’ve heard versions of those lines. If you’re a woman in orthopaedic surgery—or a woman who would like to go into orthopaedic surgery—I wonder if this is what you imagine the specialty is saying to you right now. Lip service from professional societies and residency programs notwithstanding, the substantial absence of women from our specialty and the lack of progress toward remedying this disparity over time (it came up as a theme when I interviewed for a residency in the last millennium [14]) has been exposed in this month’s CORR® so plainly that even the severest case of musculoskeletal innumeracy can discern it.

According to a multicenter study by Atul F. Kamath MD and his team at the Cleveland Clinic (as well as University of Utah and the Brigham and Women’s Hospital in Boston, MA, USA) [1], if we don’t bend the curve, it will take 217 years for our specialty to achieve gender parity with the proportion of women in medicine, which is about 36%. If we think that the specialty should reflect the population that it serves (about half women), that won’t happen until the year 2354.

A curve so flat does not deserve to be called a curve at all.

Tackling this problem is no mere feel-good exercise. Having specialties reflect the patient populations that they care for is a matter, quite literally, of life and death [13]. Providers’ good intentions are not enough; some level of shared cultural commonality between doctors and their patients is important, whether that is gender, ethnicity, or other elements of one’s identity. For those who think this doesn’t really apply to orthopaedic surgeons—many of us don’t make life-and-death decisions every day—I’d still contest your widely shared [2] but mistaken perception. Provider-driven racial disparities in care delivery cause harm to patients with musculoskeletal injuries and diseases [3]. Both women and racial minorities are badly underrepresented in orthopaedic and musculoskeletal research studies [7, 24], leaving us with knowledge gaps that can maim or kill [10, 21].

Literally every other medical and surgical specialty has overcome this problem to a greater degree than has orthopaedic surgery; we’re dead last in gender diversity [6]. Looking earlier in the process, some medical schools have done an especially good job of considering the communities they serve and approaching the concept of diversity in thoughtful ways [22]. But the real successes have been fruits of some very intense labor; specific, intentional outreach efforts that have in some cases involved pipelines reaching all the way down to middle schools [12].

Sound like too much effort? I guess that depends on how you feel about another 326 years of preventable musculoskeletal injury, harm, and death.

Join me as I go behind the discovery with the senior author of this important if somewhat dispiriting study, Atul F. Kamath MD, in the Take 5 interview that follows.

Take 5 Interview with Atul F. Kamath MD, senior author of “How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry”

Seth S. Leopold MD: Congratulations on this study. A day brightener, it is not. Let’s start with some big-picture background: Medical schools were about 6% women in 1950 [16]. That’s the percentage in our specialty today, more or less [14]. The problem in medicine was solved in part by a 1970 class-action suit brought against every medical school then receiving federal aid by the Women’s Equity Action League, which claimed the schools had discriminated against women in recruiting and admissions [17]. If we don’t move more swiftly toward solutions from within, what’s keeping any external entity from forcing change through the courts?

Atul F. Kamath MD: Clearly, there has been a tremendous movement toward gender parity in medicine since that landmark case—over 50% of current medical students are women [4]. However, whether something similar would occur to increase the representation of women in our specialty in particular remains unclear. It does not appear that gender affects the odds of acceptance to orthopaedic surgery residencies [18]. Rather, the bigger issue seems to be decreased interest in the field among women applicants. This issue is multifactorial, but I think a large part of it stems from the poor perception women have of our field—a perception that may be justified given the gender bias and harassment that women working in orthopaedics continue to experience [25]. Therefore, while I do not believe we will see the courts get involved any time soon, I would like to see stronger zero tolerance policies be implemented and enforced by our self-governing bodies.

Atul F. Kamath MD.

Dr. Leopold: Every other specialty has overcome the gender gap to a greater degree than has orthopaedic surgery [6]. All the same excuses and stereotypes—perhaps except for the hammers, screwdrivers, and brute strength thing—were common to specialties when they were dominated by men, and all of them managed to do better than we have. Why is that, and, more importantly, what can we learn from the other surgical subspecialties that have done so much better?

Dr. Kamath: The “boys club” and “brute strength” mentality obviously play a role. I also think the lack of women mentors available for women medical students interested in orthopaedics only further complicates the problem [5, 9]. I don’t think there is a clear answer as to why orthopaedic surgery has failed to catch up to these other specialties that historically have had a similar gender gap. However, I do believe that the orthopaedic community should not be afraid to ask for help from organizations that have achieved greater strides in these other fields. For example, I would like to see future collaboration with organizations such as the American Medical Women’s Association or the Association of Women Surgeons to see their perspective on what has and hasn’t worked with other fields. Fresh ideas outside of what is being tried in orthopaedics clearly are needed. Until then, what we can learn from these other medical and surgical specialties is this: It is not impossible to achieve gender parity, we just have to actually acknowledge that it is a problem, and then do something about it.

Dr. Leopold: I asked a version of this question to an author a few months ago [15], and I’ll ask it to you as well: You suggest that medical schools need to solve this problem, and they should do this by mandating orthopaedic rotations. But we don’t get to tell medical schools what to do, and every specialty lobbies curriculum committees for “more.” What’s keeping medical schools from saying, “Interesting suggestion, but problems of sexism and discrimination in your specialty are your specialty’s problems to solve, not ours.” Nothing’s worked so far in terms of broad curricular change at the medical-school level. How can we get them to see it differently?

Dr. Kamath: The American Association of Medical Colleges is committed to diversifying the entire healthcare workforce and improving patient care through this diversity. What better way to achieve these goals than to target the medical specialty that has consistently failed to “bend the curve” for gender equality?

Echoing Dr. LaPorte’s previous take on this question [15], I don’t necessarily think that medical schools need to solve this problem alone—this has to be a collaborative effort with all levels of orthopaedic education and leadership working to break down the barriers contributing to this gender gap. However, without a substantial change from the earliest step in the “pipeline,” downstream efforts won’t be enough to avoid at least two more centuries of gender inequality. Having students complete an orthopaedic surgery rotation is a simple and now an evidence-based method of improving diversity in orthopaedics [20]. I would encourage medical schools to use that information, as well as our findings, to better recognize how much we need their help to promote diversity in our field.

Dr. Leopold: You also pointed to the Accreditation Council for Graduate Medical Education as well as our Academy as possible entities with a role to play in terms of benchmarking and career development programs, respectively. As much as I like those ideas, it feels like we’ve been hearing them for a long time now. I’m not sure I see the movement coming, and your “curves” suggest that if someone doesn’t change the game—bigtime—it won’t come for, well, centuries. Can you give me some reason to be hopeful? The old approaches seem not to be cutting it.

Dr. Kamath: I agree that it is difficult to be optimistic after seeing our findings, as well as various other studies showing how little we’ve progressed during the past 50 years. But I still have hope that we can change this narrative and achieve gender equality in orthopaedics sooner than we projected. Even though the data have yet to reflect this, I think our field is making important strides toward equality. For example, Kristy Weber MD becoming the first woman president of the American Academy of Orthopaedic Surgeons in 2019 was a historical moment for our profession and for the larger gender parity movement. Additionally, recently, a large volume of high-quality studies addressing the severity of these gender inequalities, as well as possible solutions, continue to be published in CORR [18, 25] and other prominent orthopaedic journals. Also, in addition to requiring all medical students to complete an orthopaedic surgery rotation [20], another promising idea relates to standardizing letters of recommendation for residency applications in order to reduce possible gender bias in the assessment of female applicants [19, 26]. That being said, I agree that these old approaches are not working. There remains a need for specific interventions to be implemented, such as having orthopaedic programs set our proposed benchmarks related to the proportion of academic faculty or incoming trainees who are women. However, I encourage the orthopaedic community to not lose faith but rather double down on efforts to make our workforce more diverse.

Dr. Leopold: What do you make of the subspecialty differences you found? There was essentially no movement at all in adult reconstruction and spine.

Dr. Kamath: I think the reason behind these subspecialty differences is multifaceted. Although this applies to the field of orthopaedics, I think the incredibly low number of women in our specialty is a direct result of our inability to connect with, recruit, and mentor women candidates. Women interested in orthopaedics already have a difficult time finding mentors of the same gender. In the field of adult reconstruction, the need for this mentorship is even more glaring, and therefore should be intentional rather than reflexive. The Hip and Knee Societies have less than 1% women membership. Multiple studies [8, 11, 23] have demonstrated that spine and adult reconstruction have some of the lowest proportions of women across academic leadership positions (faculty, program directors, etc.). Subsequently, women who want to pursue these roles may be dissuaded from these fields. When there’s limited representation in these subspecialties and their respective honorific societies, I think it is even harder for women medical students and residents to gain exposure. These barriers obviously impede any efforts at reaching gender parity in orthopaedics, and our findings serve to emphasize that these subspecialties need extra help moving forward. In our study, we propose benchmarks for training programs and subspecialty societies to help mitigate these comparably lower rates of representation. However, I would also encourage future collaboration with organizations such as the Women in Arthroplasty (Full disclosure: One of our coauthors [AFC] is a committee member) to get the perspective and advice of women orthopaedic surgeons who have overcome these barriers.