Abstract
Background
Women have historically been underrepresented as editors of peer-reviewed medical journals. Studies have demonstrated that there are differences in editorial board reviewer behavior based on gender, suggesting that greater representation by women on editorial boards may improve the quality and diversity of the review process. Therefore, the current representation of women on the editorial boards of orthopaedic journals, particularly compared with peer-reviewed surgical and medical journals, is of interest.
Questions/purposes
(1) What is the representation of women as members of editorial boards of prominent orthopaedic surgery journals? (2) How does it compare with representation on the editorial boards of journals in general surgery and internal medicine?
Methods
The top 15 journals with a strong clinical emphasis based on Impact Factor (Clarivate Analytics) calculated by the 2018 Journal Citation Reports were identified for orthopaedic surgery, general surgery (and all general surgical subspecialties), and internal medicine (with representative internal medicine subspecialties). Clinical publications with their primary editorial office located in the United States led predominantly by physicians or basic scientists were eligible for inclusion. The members of an editorial board were identified from the journals’ websites. The gender of editors with gender-neutral names (and editors whose gender we considered uncertain) was identified by an internet search for gender-specific pronouns and/or pictures from an institutional profile. Fisher exact tests and t-tests were used to analyze categorical and continuous variables, respectively. Significance was set at p < 0.05.
Results
Of the editors analyzed, women made up 9% (121 of 1383) of editorial boards in the orthopaedic journals with the highest Impact Factors, compared with 21% (342 of 1665) of general surgery journals (p < 0.001) and 35% (204 of 587) of internal medicine journals (p < 0.001). The overall mean composition of editorial boards of orthopaedic journals was 10% ± 8% women, compared with that of general surgery, which was 19% ± 6% women (p < 0.001), and that of internal medicine, which was 40% ± 19% women (p < 0.001).
Conclusion
Women make up a smaller proportion of editorial boards at orthopaedic surgery journals than they do at general surgery and internal medicine journals. However, their representation appears to be comparable to the proportion of women in orthopaedics overall (approximately 6%) and the proportion of women in academic orthopaedics (approximately 19%). Ways to improve the proportion of women on editorial boards might include structured mentorship programs at institutions and personal responsibility for championing mentorship and diversity on an individual level.
Clinical Relevance
Increasing representation of women on editorial boards may improve the diversity of perspectives and quality of future published research, generate visible role models for young women considering orthopaedics as a career, and improve patient care through enriching the diversity of our specialty.
Introduction
Historically, women have been underrepresented on the editorial boards of major peer-reviewed journals in academic medicine [23]. A 1998 investigation of public health journals found that the proportion of editorial positions held by women was smaller than the proportion of authors and reviewers who were women [9]. In 2007, investigators found that the proportion of women on the editorial and governing boards of the publications in six different specialties in medicine was smaller than the proportion of women physicians practicing in those specialties [19]. A 2011 analysis of 60 top-ranked medical journals found that women continue to be underrepresented, and only 15.9% (10 of 63) of editors-in-chief were women [2]. This disparity is important for several reasons. Studies have demonstrated that there are differences in editorial board reviewer behavior based on gender [11, 28], suggesting that greater representation by women on editorial boards may improve the quality and diversity of the review process. Amrein et al. [2] also contend that serving on editorial boards is an important experience for any investigator because it may be conducive to research funding and academic advancement. In addition, women holding editorial positions not only hold powerful roles in shaping the nature of published studies, but also serve as visible signs of progress and role models for young women considering a career in the field [2].
Orthopaedic surgery has the lowest representation of women among all specialties of medicine [1, 6, 8]. Mentors of the same gender play an important role, especially for women considering orthopaedics as a career [13, 18]. Therefore, it is particularly important for women role models to achieve advancement and leadership positions in academic orthopaedic surgery. A recent study examined the gender composition of editorial boards and first and last authors of three prominent orthopaedic journals: The Journal of Bone and Joint Surgery, American Volume; the Journal of the American Academy of Orthopaedic Surgeons; and Clinical Orthopaedics and Related Research® [24]. These authors found that the proportion of first and last authors who were women increased from 6% in 1997 to 13% in 2017, and that the proportion of editorial board members who were women increased from 3% in 1997 to 9% in 2017 [24]. However, to our knowledge, a more comprehensive comparison of the representation of women on the editorial boards of additional peer-reviewed journals in orthopaedics with that of journals in other medical specialties has yet to be reported.
Therefore, we aimed to answer the following questions: (1) What is the representation of women as members of editorial boards of prominent orthopaedic surgery journals? (2) How does it compare with representation on the editorial boards of publications in general surgery and internal medicine?
Materials and Methods
The 15 leading journals, based on Impact Factor (Clarivate Analytics) calculated by the 2018 InCites Journal Citation Reports, were identified for orthopaedic surgery (Table 1), general surgery (Table 2), and internal medicine (Table 3) [7]. Clinical publications with their primary editorial office in the United States led by physicians or basic scientists were eligible for inclusion. Orthopaedic journals were identified by the orthopedics category from the Journal Citation Reports database. We excluded the following from the analysis: physical therapy journals, basic science–only journals, and nonoperative sports medicine journals, because the goal was to examine the editorship of clinically oriented journals specific to the field of orthopaedic surgery. General surgery journals were identified by the surgery category from the InCites database. All general surgery subspecialties, defined as specialties that traditionally matriculate from a general surgery training program such as cardiothoracic surgery, transplant surgery, surgical oncology, and trauma surgery, were included in the general surgery category. On the other hand, neurologic surgery, otolaryngology, and plastic surgery were considered separate specialties because they have separate categorical training programs and were therefore not included. For internal medicine, an initial search was based on the category of medicine, general and internal, and expanded to include representative journals with high Impact Factors from the subspecialties of hematology, oncology, cardiology, pulmonology, gastroenterology, endocrinology, and allergy and immunology. Basic science–only journals in the surgery and internal medicine categories were also excluded from the analysis.
Table 1.
Orthopaedic surgery journals
| Journal | Impact Factor | Editorial board total | Percentage of women (n) | Woman as editor-in-chief? |
| American Journal of Sports Medicine | 6.093 | 170 | 5% (8) | No |
| Journal of Bone and Joint Surgery, American Volume | 4.716 | 38 | 18% (7) | No |
| Arthroscopy - The Journal of Arthroscopic and Related Surgery | 4.433 | 117 | 3% (3) | No |
| Clinical Orthopaedics and Related Research ® | 4.154 | 88 | 15% (13) | No |
| Journal of Arthroplasty | 3.524 | 206 | 4% (9) | No |
| Spine Journal | 3.196 | 129 | 7% (9) | No |
| Journal of Orthopaedic Research | 3.043 | 142 | 25% (35) | Yes |
| Spine | 2.903 | 144 | 45% (7) | No |
| Journal of Shoulder and Elbow Surgery | 2.865 | 40 | 13% (5) | No |
| Orthopaedic Journal of Sports Medicine | 2.589 | 149 | 3% (5) | No |
| Orthopedic Clinics of North America | 2.475 | 6 | 0% (0) | No |
| Journal of the American Academy of Orthopaedic Surgeons | 2.348 | 21 | 14% (3) | No |
| Foot and Ankle International | 2.341 | 38 | 3% (1) | No |
| Journal of Hand Surgery, American Volume | 2.09 | 49 | 20% (10) | No |
| Journal of Pediatric Orthopaedics | 2.046 | 46 | 13% (6) | No |
| Mean ± SD | 92 ± 62 | 10% (8) ± 8% (8) |
Table 2.
General surgery journals
| Journal | Impact Factor | Editorial board total | Percentage of women (n) | Woman as editor-in-chief? |
| JAMA Surgery | 10.668 | 41 | 27% (11) | Yes |
| Annals of Surgery | 9.476 | 162 | 25% (40) | No |
| Journal of Heart and Lung Transplantation | 8.578 | 67 | 15% (10) | No |
| American Journal of Transplantation | 7.163 | 106 | 25% (27) | No |
| Journal of Thoracic and Cardiovascular Surgery | 5.261 | 115 | 9% (10) | No |
| Journal of the American College of Surgeons | 4.45 | 105 | 22% (23) | No |
| Liver Transplantation | 4.159 | 114 | 18% (20) | No |
| Diseases of the Colon and Rectum | 4.087 | 55 | 13% (7) | Yes |
| Annals of Thoracic Surgery | 3.919 | 101 | 24% (24) | No |
| Surgery for Obesity and Related Diseases | 3.758 | 104 | 20% (21) | No |
| Annals of Surgical Oncology | 3.681 | 247 | 30% (75) | No |
| Obesity Surgery | 3.603 | 139 | 17% (23) | No |
| Surgery | 3.476 | 104 | 16% (17) | No |
| Journal of Trauma and Acute Care Surgery | 3.377 | 145 | 19% (28) | No |
| Journal of Vascular Surgery | 3.243 | 60 | 10% (6) | No |
| Mean ± SD | 111 ± 51 | 19% (23) ± 6% (17) |
Table 3.
Internal medicine journals
| Journal | Impact Factor | Editorial board total | Percentage of women (n) | Woman as editor-in-chief? |
| New England Journal of Medicine | 70.67 | 51 | 39% (20) | No |
| Lancet | 59.102 | 18 | 78% (14) | No |
| JAMA - Journal of the American Medical Association | 51.273 | 32 | 28% (9) | No |
| Lancet Oncology | 35.386 | 6 | 83% (5) | No |
| Journal of Clinical Oncology | 28.349 | 20 | 20% (4) | No |
| Circulation | 23.054 | 65 | 29% (19) | No |
| Annual Review of Immunology | 21.429 | 8 | 50% (4) | No |
| JAMA Internal Medicine | 20.768 | 41 | 41% (17) | Yes |
| Gastroenterology | 19.809 | 37 | 22% (8) | No |
| Annals of Internal Medicine | 19.315 | 54 | 46% (25) | Yes |
| Journal of the American College of Cardiology | 18.639 | 35 | 23% (8) | No |
| Blood | 16.601 | 117 | 34% (40) | Yes |
| American Journal of Respiratory and Critical Care Medicine | 16.494 | 44 | 25% (11) | Yes |
| Endocrine Reviews | 15.167 | 10 | 50% (5) | No |
| Journal of Allergy and Clinical Immunology | 14.11 | 49 | 31% (15) | No |
| Mean ± SD | 39 ± 28 | 40% (14) ± 19% (10) |
The focus of our analysis was the proportion of women on the editorial boards of the journals we included. Editorial boards were identified from the journals’ websites, accessed between October 5, 2020 and October 25, 2020. Editors emeriti, managing editors, and consulting or advisory editors were not included. Excel spreadsheets of the names of all included editors were created, and the gender was recorded. Because 3635 editors were included in this study, a separate internet search for each person was not performed. For anyone with a gender-neutral name or if there was any degree of uncertainty regarding the editor’s gender, we performed an online search for gender-specific pronouns and/or pictures from an institutional profile of that editor. We did not encounter any cases in which an editor’s gender could not be determined. We also did not encounter any apparent cases in which editors considered themselves gender nonbinary. The mean number of editors analyzed for orthopaedic journals was 92 ± 62, compared with 111 ± 51 for general surgery editors and 39 ± 28 for internal medicine editors.
Primary and Secondary Study Outcomes
Our primary study goal was to examine the gender composition of editorial boards. To achieve this, we calculated two summary measures: the overall proportion of women, calculated by the total number of women divided by the total number of editors of all 15 journals analyzed in each category, and the mean proportion of women on editorial boards, determined by calculating the mean of the proportions for each of the 15 journals included. This second summary measure was included so that journals with a smaller number of editorial board members were not underrepresented.
Our secondary study goal was to compare the proportion of women editors of orthopaedic journals with that of journals in general surgery and internal medicine. We performed comparisons using the statistical tests described below. In addition, we examined how many of the 15 journals in each category had an editor-in-chief who was a woman.
Ethical Approval
Because this was a cross-sectional study of publicly available, non-patient data gleaned from an internet search, ethical approval was not sought for the present study.
Statistical Analysis
Fisher exact tests and t-tests were used to analyze categorical (overall proportions of women) and continuous variable data (the mean of the proportions for each of the 15 journals), respectively. Statistical significance was considered as a p value less than 0.05.
Results
Representation of Women on Orthopaedic Editorial Boards
Women comprised 9% of editorial boards in the orthopaedic journals we surveyed (121 of 1383 editors). The overall mean composition of editorial boards of orthopaedic journals by women was 10% ± 8%.
Comparing Orthopaedic with Surgical and Internal Medicine Editorial Boards
Women were better-represented on general surgical journals’ editorial boards than on orthopaedic journals’ editorial boards (21% [342 of 1665] versus 9% [121 of 1383], odds ratio 2.5 [95% CI, 2.0-3.1]; p < 0.001) and on internal medicine journals’ editorial boards (35% [204 of 587], odds ratio 5.6 [95% CI, 4.3-7.1]; p < 0.001). The mean composition of editorial boards of orthopaedic journals of 10% ± 8% women was smaller than that of general surgery, which was a mean of 19% ± 6% women (mean difference 9% ± 3% [95% CI, 4%-15%]; p < 0.001) and that of internal medicine, which was 40% ± 19% women (mean difference 30% ± 5% [95% CI, 19%-41%]; p < 0.001). One editor-in-chief among the orthopaedic journals analyzed was a woman, compared with two among general surgery and four among internal medicine publications.
Discussion
Underrepresentation of women on the editorial boards of medical journals deserves attention, because women holding editorial positions may provide greater diversity in the review process and improve the quality of published studies that represent progress in that field [11, 28]. In addition, editorship of peer-reviewed journals may serve not only as opportunities for academic advancement but also as proxies for representation in the field for those considering it as a career [2]. This is important because low representation of women persists in orthopaedic surgery, from resident to faculty [4, 5]. Improving this disparity is critical for both providers and patients. Better representation of women in orthopaedics will attract more top medical students to pursue this field, ultimately advancing the quality of care of patients with musculoskeletal conditions [3, 13]. Moreover, greater diversity in the physician workforce enriches the quality of the educational process, patient care, and patient satisfaction [13, 22, 27]. For these reasons, we aimed to investigate the proportion of women on orthopaedic editorial boards and to assess how the representation of women on editorial boards in orthopaedic surgery journals compared with that of journals in other fields of medicine. We found that the proportion of women editors in orthopaedics was lower than that of general surgery and internal medicine. These findings accentuate the gender diversity challenge that orthopaedics has with its pipeline [8, 18]; as fewer women pursue orthopaedics as a career, there are fewer women to serve as editors and play a role in shaping the future studies of the field. Both editorial leadership and individuals in the field of orthopaedic surgery should take steps to combat these challenges.
Limitations
This study has limitations. Information regarding the academic degrees and institutional affiliations of editors was not always provided by the journals, and not all editors included in the analysis may have been practicing physicians in orthopaedic surgery, general surgery, or internal medicine. In fact, the one woman editor-in-chief in the surveyed orthopaedic surgery journals (Table 1) is a basic scientist. Additionally, basic science investigators and physicians practicing in specialties outside the particular journals’ focuses may have been included. We consider this a limitation because these editors do not necessarily represent women orthopaedic surgeons who advance in their careers into an editorial or other leadership role. However, we do not believe this disqualifies these findings, because they answer our questions regarding the representation of women on editorial boards of orthopaedic journals and how they compare to that of other fields in medicine. Editors who are women, regardless of their position in academic medicine, are able to enhance diversity and shape and improve the future research of their field.
Another limitation is that we did not have a reliable way to deduce the levels of responsibility of the various editorial positions analyzed. We included all ranks of editorial boards in the analysis in the current study, but it would be interesting to further compare the various levels of editors among orthopaedics, general surgery, and internal medicine in terms of gender representation. However, a certain title of an editorial position of one journal may confer a substantially different level of responsibility than a position with the same title in another journal.
Representation of Women on Orthopaedic Editorial Boards
We found that approximately 9% of editors in the orthopaedic journals we surveyed were women (121 of 1383 editors). This was similar to the percentage reported by Rynecki et al. [24], who found that in 2017, women comprised 9% of editors (10 of 107) of The Journal of Bone and Joint Surgery, American Volume; the Journal of the American Association of Orthopaedic Surgeons; and Clinical Orthopaedics and Related Research®. Our study expands on the investigation performed by Rynecki et al. [24] because we examined 15 orthopaedic surgery journals with the highest Impact Factor, finding that this low representation of women persisted when considering additional journals, and we further compared orthopaedic surgery with other specialties. Although the percentage of women editors of orthopaedic journals may be greater than the percentage of women practicing in orthopaedic surgery as a whole (approximately 6.5% [6]), it may be lower than the proportion of women faculty members in academic orthopaedics (19% [16]), although a formal statistical comparison was not performed. Increasing the proportion of women editors at orthopaedic journals will require focusing attention on the pipeline. Individuals may not be able to serve on an editorial board until they have first served as reviewers, and they generally will not be invited to review until they have published research that demonstrates their expertise. Editors tend to be senior investigators in their specialties and might be invited through networks such as governing boards of professional societies and conferences [2, 9]. The proportion of women in academic orthopaedics is the highest for the junior ranks of instructor and assistant professor [10, 16]. Therefore, the proportion of women orthopaedic surgeons in the selection pool being considered for editorship may be lower than the proportion of women in academic orthopaedics.
Another explanation for the low proportion of women in leadership positions is that women simply do not pursue them. Sharkey et al. [25] investigated academic pediatric orthopaedics, finding that candidate and active members of the Pediatric Orthopaedic Society of North America who are women participated at lower rates than their counterparts who are men in terms of authorship at annual Pediatric Orthopaedic Society of North America meetings. In contrast, Poon et al. [21] found that women in the Pediatric Orthopaedic Society of North America applied for the society’s committees at higher rates than men and at a greater proportion than the proportion of women in this society. Nevertheless, representation of women in the high levels of Pediatric Orthopaedic Society of North America leadership remains lower than the percentage of women members [21]. In our study, only one of the 15 orthopaedic journals had a woman serving as editor-in-chief. Of note, the woman holding that position at the time of this study was not a clinical orthopaedic surgeon, but a professor in orthopaedics, cell biology, and physiology who had a PhD. In addition, the data by Rynecki et al. [24] suggest that most women serve as junior associate editors rather than more-senior deputy editors of orthopaedic journals; the authors contend this may be because a large proportion of women orthopaedic surgeons are early in their careers and have not had time to advance to more-senior editor positions.
Comparing Orthopaedic with Surgical and Internal Medicine Editorial Boards
General surgery and internal medicine journals had higher percentages of women editors than did orthopaedic journals in our study. When considering the proportion of women editors in general surgery (21% overall; 19% mean composition), it is notably more similar to the proportion of women faculty in academic general surgery (26% [16]). These data regarding the gender representation of faculty were obtained through a survey of medical schools that only 63.6% of schools responded to, so the true proportion of women faculty may not be represented [16]. Nevertheless, we expect that most physician editors of medical journals practice in an academic setting, and this apparent discrepancy between the proportion of editors and academic orthopaedic faculty who are women suggests there may be barriers for women serving in senior roles on editorial boards, even for women already in the field. This finding parallels the result of previous studies that suggest physicians who are women face barriers to academic advancement [14, 15, 26]. However, other specialties such as general surgery are making greater progress in improving the diversity of their editorial boards. Harris et al. [12] found that the representation of women on the editorial boards of 10 high-impact general surgery journals has steadily increased over 20 years—faster than the presence of women in general surgery academic positions and faster than increases in journal board size. These authors contend this is because of proactive appointment of women by editors-in-chief. Leaders in the orthopaedic surgery publishing community should consider being proactive in their appointment and recruitment of women on their editorial boards. For filling vacant academic surgical faculty positions, authors have suggested applying the Rooney Rule, which would require the institution to consider at least one woman or underrepresented minority as a candidate [5]. An established initiative to apply a similar requirement could be considered for filling senior-level editorial positions, which may enhance the representation of women in orthopaedic journals. In addition, mentorship is critical to encourage young women to consider orthopaedics, as well as foster the advancement of women already in the field [18, 20]. Institutions should be encouraged to establish mentorship structures in their department so that senior faculty can provide guidance for their junior faculty on how to advance their academic careers and eventually have the opportunity to serve on editorial boards. Although women in orthopaedic surgery are more likely to indicate that a role model of the same gender influenced their decision to enter this field [13], most potential mentors in orthopaedics remain men. Therefore, individually, all of us in this field should be encouraged to take personal responsibility to promote mentorship and sponsorship and seek solutions to underrepresentation [6, 17].
Conclusion
Women make up a smaller proportion of editorial boards at orthopaedic surgery journals with the highest Impact Factors than they do at general surgery and internal medicine journals, though at least their representation appears to be comparable to the proportion of women in orthopaedic surgery as a whole and in academic orthopaedics. Representation of women on editorial boards improves the diversity and quality of the review process and creates opportunities for career advancement for women, and women on editorial boards serve as visible role models for young women considering orthopaedics as a career. Ways to improve this disparity include structured mentorship programs at institutions and personal responsibility to champion mentorship and diversity on an individual level. Future work might include monitoring the gender composition of editorial boards over time to investigate whether the representation of women improves as more women enter this field, advance their careers, and eventually ascend the ranks of editorial leadership.
Acknowledgments
We thank Maurice Manring PhD for sharing with us his expertise in academic medical research and the publication process, and his guidance in preparing this manuscript.
Footnotes
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that neither he nor she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Ethical approval was not sought for the present study.
This work was performed at the Ohio State University Wexner Medical Center, Columbus, OH, USA.
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