Does Medical Students’ Sense of Belonging Affect Their Interest in Orthopaedic Surgery Careers? A Qualitative Investigation

Abstract

Background

The concept of social belonging has been shown to be important for retention and student success in collegiate environments and general surgery training. However, this concept has never been explored in relation to medical students’ impressions of orthopaedic surgery careers.

Question/purpose

To investigate medical students’ sense of belonging in orthopaedic surgery and how it affects their interest in pursuing orthopaedic surgery careers.

Methods

Medical students from four medical schools were invited to participate in telephone interviews aimed to investigate medical students’ reasons for considering (or not considering) orthopaedic surgery as a future career. Students were selected using random sampling and theoretical sampling methods (selecting participants based on specific characteristics) to obtain a diversity of student perspectives across medical school year, gender, race, age, and interest in orthopaedics. Semistructured interviews with open-ended questions and face validity were used to minimize bias in the interview process. Analysis was performed using grounded theory methodology, a rigorous and well-established method for creating conceptual models based on qualitative data. The result seeks to be a data-driven (as opposed to hypothesis-driven) theory that provides perspective on human behavior. Interviews were conducted until the point of thematic saturation, defined as the point when no new ideas occur in subsequent interviews; this was achieved at 23 students (16 self-identified as women, 12 self-identified as underrepresented minorities).

Results

Medical students articulated stereotypes about orthopaedic surgeons, in particular, that they were white, male, and athletic. Students derived their sense of belonging in orthopaedic surgery from how closely their identities aligned with these stereotypes about the field. Students who felt a sense of belonging described themselves as being part of a cultural “in-group,” and students who did not feel a sense of belonging felt that they were in a cultural “out-group.” Members of the in-group often reported that orthopaedic experiences further reinforced their positive identity alignment, which typically led to increased interest and continued engagement with the field. Conversely, students in the out-group reported that their exposures to orthopaedics further reinforced their lack of identity alignment, and this typically led to decreased interest and engagement. Many students in the out-group reported pursuing other specialties due to a lack of belonging within orthopaedics.

Conclusion

Students derive their sense of belonging in orthopaedics based on how closely their identity aligns with stereotypes about the field. Importantly, there were gender and racial factors associated with orthopaedic stereotypes, and thus with belonging (self-identifying as the in-group). Moreover, out-group students tended not to choose orthopaedic surgery careers because of a lack of belonging in the specialty.

Clinical Relevance

With knowledge of the factors that influence students’ sense of belonging, academic orthopaedic departments can focus on interventions that may lead to a more diverse pool of medical students interested in orthopaedic surgery. These might include explicitly addressing stereotypes about orthopaedics and cultivating positive identity alignment for students from diverse backgrounds through targeted mentorship fostering partnerships with affinity organizations, and creating space to talk about barriers. Targeted interventions such as these are needed to interrupt the cycle of in-group and out-group formation that, in this small multicenter study, appeared to deter students with underrepresented identities from pursuing orthopaedic surgery careers.

Introduction

Orthopaedic surgery is the least diverse medical specialty in the United States [1, 2] and continues to lag in recruiting medical students from varied backgrounds. Although the percentage of women students entering medical school in the country has increased from 11% in 1970 to 48% in 2011, the percentage of women in orthopaedic surgery has only increased from 1% to 9% during this same period [8]. Orthopaedics has the lowest percentage of trainees who are women among surgical specialties nationally [27], and this pattern persists throughout all career phases [3]. Additionally, there are important disparities for racial and ethnic minorities. The proportion of applicants from minority racial or ethnic groups to orthopaedic residency programs is low compared with that of other specialties [6] and actually decreased over the past decade [27]. Overall, 75% of orthopaedic faculty in the United States identify as white, 2% of faculty identify as Black, and 2% identify as Hispanic or Latino [4]. Furthermore, the number of women and racial or ethnic minorities decreases in higher academic ranks, a phenomenon referred to as the “leaky pipeline” [11, 30]. The lack of diverse representation in orthopaedic academic leadership and limited mentorship may have a negative impact on recruiting diverse medical students to the specialty, thus perpetuating the cycle [11, 18, 25]. These patterns persist despite an increased focus on diversity and inclusion efforts over the past decade, as well as abundant data showing that diversity improves institutional outcomes, the quality of team decisions, and healthcare outcomes for patients [15, 28, 33]. Our lagging progress in achieving diversity suggests that our current understanding of diversity and inclusion in orthopaedics is inadequate to attract greater numbers of women and underrepresented minorities to the field.

Perceived fit has been identified as an important factor in medical student specialty selection. Data from the American Association of Medical Colleges Graduation Questionnaire show that the strongest influence on medical student specialty choice is “fit with personality, interest, and skills,” with 87.2% of all graduating medical students indicating that this had a strong influence on their specialty choice [5]. In social science research, social belonging, defined as “a sense of having positive relationships with others,” has been well recognized as a fundamental human motivation [7, 38]. The importance of social fit and belonging in academia is based on a simple principle: if students feel they belong in a particular environment (such as an academic department), they are more likely to stay engaged with that environment [10, 38]. The concept of social belonging has also been studied in general surgery, with a positive correlation between resident retention, belonging, and well-being [29]. These studies show the importance of social fit and belonging in education, and specifically in surgical training. However, no research that we know of has examined these factors qualitatively from the medical student’s perspective, or in the context of choosing orthopaedic surgery as a career.

We therefore sought to investigate medical students’ sense of belonging in orthopaedic surgery and how it affects their interest in pursuing orthopaedic surgery careers.

Materials and Methods

Participants and Data Acquisition

Four Midwest medical schools (Washington University in St. Louis School of Medicine, Loyola University, Saint Louis University, and University of Michigan) were selected for their varying characteristics, including student body size, public versus private school ownership, and medical school research rank [34]. Medical education representatives from these institutions emailed all current medical students inviting them to participate in a survey about belonging in orthopaedic surgery. The email contained an informed consent document and an anonymous link to the survey. After completing and submitting the survey, students could provide their email address on a separate form if they were interested in participating in a telephone interview. Students were told that the purpose of the interview was “to help us better understand medical students’ reasons for considering (or not considering) orthopaedic surgery as a future career.” Twenty-two students provided their contact information for an interview, and students were sequentially selected for interviews using a random-number generator. This strategy for participant selection was chosen to capture a wide array of student experiences, depth of exposures to orthopaedics, interest in orthopaedic careers, and diversity of demographic characteristics while also protecting student privacy. After interviewing 16 students using this initial selection strategy, themes around gender and racial identity had become important concepts in our model.

A second phase of interviews was then performed using theoretical sampling, a strategy in which investigators seek additional data based on concepts developed from initial data analysis. Accordingly, additional interviews were conducted with medical students who identified as women (six students) and underrepresented minorities in medicine (seven students), working sequentially until thematic saturation was achieved [14]. The concept of thematic saturation is defined in plain language by Urquhart [35] as “the point in coding when you find that no new codes occur in the data. There are mounting instances of the same codes, but no new ones.” Additionally, Glaser and Strauss [14] emphasize the importance of the researchers going out of their way to look for groups that stretch the diversity of the data as far as possible, to ensure that thematic saturation is based upon the widest possible range of data. Through the process of random sampling supplemented by rigorous theoretical sampling, we ensured that all perspectives were sought, collected, and included in our model.

Interview Content

Interviews were conducted using a semistructured format (Supplemental Digital Content 1, http://links.lww.com/CORR/A550). Predetermined questions were developed to be open-ended and allow the students to share both positive and negative impressions and experiences related to orthopaedic surgery. These questions were constructed and refined by several qualitative experts (DBJ, AS) on our study team, with the goals of achieving face validity and creating an unbiased instrument. Importantly, to decrease the chance that students’ answers were biased by our interview questions, we structured our questions so that students were asked about their general impressions of orthopaedics and their perspective on belonging and fit before being prompted with questions about gender and racial diversity in the field.

Interview Process

Participants received an informed consent document via email and verbally provided consent over the telephone. The interviews were audio recorded using Zoom. Participants received a USD 25 Amazon gift card as compensation for participating in the interview. The audio recordings were subsequently deidentified to ensure confidentiality. The audio transcription software Trint was used to convert the audio recordings to text transcripts. The transcripts’ accuracy was verified by two authors (KMG, PP), and any further identifying information (such as institution name, peer names, attending physician names, and mentor names) was removed. The deidentified data were uploaded into Dedoose for data analysis.

Interviews with medical students were conducted from December 2019 to December 2020. Interviews lasted an average of 30 minutes, and interviews were conducted by a single interviewer (KMG) with experience in qualitative research and no professional ties to the interviewees. Participants spanned all four years of medical school, with five first-year students, five second-year students, one MD-PhD student in lab years, nine third-year students, and three fourth-year students. Sixteen of the participants self-identified as women and seven self-identified as men. Twelve participants self-identified as underrepresented minorities (Table 1). In all interviews, themes about belonging and its influence on the student’s interest in orthopaedics emerged.

Table 1.

Demographic characteristics

Participant characteristics	Number of participants
Medical school year
M1	5
M2	5
M3	9
M4	3
MD/PhD in research years	1
Age in years, median (range)	25 (24-29)
Gender
Men	7
Women	16
Race or ethnicity
White	11
Asian	3
Hispanic	3
African American	4
Middle Eastern or North African	1
Multiracial	1
LGBTQIA identity
Yes	1
No	22
Orthopaedics as top-choice future specialty
Yes	9
No	14
Any surgical specialty in top three specialties
Yes	20
No	3

LGTBQIA = lesbian, gay, bisexual, transgender, queer, intersex, and/or agender.

Data Analysis

We used the grounded theory method detailed by a few authors [12, 14, 22] to conceptualize a theoretical model of medical students’ perceptions of belonging and inclusion in orthopaedic surgery. Grounded theory is a well-established, inductive method for analyzing qualitative data. An inductive method is defined as one that seeks to generate behavioral theories from data, as opposed to attempting to fit data into a pre-existing model [14, 16]. Grounded theory is an approach to interpreting qualitative data that allows for a comprehensive understanding of individual narratives through the process of (1) coding raw data, (2) categorizing and combining codes into themes, and (3) forming a conceptual (theoretical) model based on the themes [12, 23]. Data were analyzed via this three-step process, beginning with open coding (identifying small ideas that signify meaning), followed by axial coding (defining themes from the generated codes), and concluding with selective coding (forming a conceptual model based on the themes that emerged) [12, 26, 32]. Both investigators (KMG, PP) independently read and coded all transcripts. Each of the coders (KMG, PP) documented their process of coding with memorandum-writing and note-taking; then they discussed any coding discrepancies and reached consensus on coding to develop the conceptual schema. Throughout the study, the authors maintained journals with the goal of fostering transparency and critical self-reflection[24], and wrote analytic and theoretical memos according to the principles of grounded theory design [12, 14]. Frequent communication through memo writing allowed the investigators to continually refine their theory, challenge emerging assumptions, and raise insights while also highlighting one another’s own subjectivities as researchers [12]. Open coding produced a codebook with 161 codes. These codes generated the themes that will be discussed in detail below, and ultimately resulted in a conceptual model that describes medical students’ perceptions of belonging in orthopaedic surgery. Quotes presented in-text and within the tables were selected to be representative examples of the theoretical concepts in our study. Of note, student quotes are coded as [year in medical school (M1-M4) _ gender (M = man, W = woman) _ study ID number (01 to 23)]; for example [M2_M_04].

Ethical Approval

Ethical approval for this study was obtained from Washington University in St. Louis, St. Louis, MO, USA (ID number 201910173).

Results

Overall Model Framework

Our data resulted in a conceptual model that describes the complex relationships between stereotypes about orthopaedic surgery and students’ sense of belonging in orthopaedics (Fig. 1).

Fig. 1.

This chart shows a conceptual framework of medical students’ belonging in orthopaedic surgery.

All medical students articulated stereotypes about orthopaedic surgery, particularly that the field was predominantly comprised of white, athletic men. Students tended to ask themselves if they had a sense of belonging in orthopaedic surgery based on how closely their identity aligned with these stereotypes. Students who reported feeling a sense of belonging in orthopaedics described themselves as being in a cultural “in-group,” and students who did not feel a sense of belonging felt that they were in a cultural “out-group” in orthopaedics. Importantly, gender and race were strong components of orthopaedic stereotypes, and thus associated with in-group/out-group identification. When members of the in-group had experiences with orthopaedics they reported that these experiences further reinforced their identity alignment. This led to a strong sense of fitting in, which typically resulted in continued engagement with the field and contributed to cycles of like-minded students pursuing orthopaedics. Conversely, students in the out-group reported that orthopaedic experiences further reinforced their lack of identity alignment and led to a sense of not fitting in, which usually decreased their interest in orthopaedics.

Although most out-group students reported pursuing other specialties, a small number of out-group members expressed an interest in becoming orthopaedic surgeons despite reporting an overall lack of belonging. These out-group students said they were motivated to directly counteract the exclusive in-group culture and create positive identity alignment for students who also shared nonstereotypical orthopaedic surgery identities. The details of this “trailblazing” attitude in the conceptual model are described below.

Medical Students Hold Preconceived Notions and Stereotypes about Orthopaedics

Students described several stereotypical characteristics associated with orthopaedic surgery. They described the field as dominated by men, predominantly white and sports-focused (Fig. 2). Many sources of information contributed to medical students’ stereotypes about orthopaedic surgery. Participants described making assumptions about orthopaedic surgery based on social media posts, television, jokes, and internet forums. The impact of stereotypes arising from general society (as opposed to medical communities or institutions) was seen in the type of students who expressed interest in orthopaedic surgery very early in medical school. As a first year-student stated, “I think an interesting data point is [who attends the] orthopaedic surgery interest group meeting at the start of first year. [I] looked around and it fit the stereotype of who you would expect to be there: Guys that are all five-ten and up, rather athletic, kind of the ‘fratty’ ‘bro-y’ types in our class. [I was] like, ‘yup, it makes sense that you’re here’” [M1_W_02]. This quote illustrates how stereotypes about orthopaedics form before students begin medical school and are then reinforced by their experiences as medical students.

Fig. 2.

This chart shows medical students’ preconceived notions and stereotypes about who an orthopaedic surgeon is.

Students’ Alignment with Orthopaedic Stereotypes Leads to In-Group and Out-Group Formation

Students’ sense of belonging in orthopaedic surgery tended to be based on how closely their identity aligned with the various stereotypes about the field. Thus, intersectionality (that is, the way in which various aspects of an individual’s identity combine/compound with resulting implications on discrimination and privilege [31]), played a role in the extent to which students reported a sense of belonging in orthopaedics (Fig. 2). This concept is illustrated by the same first-year medical student, who discussed the interplay among her gender, race, and socioeconomic privilege: “As much as we talk about gender in [orthopaedics], at the end of the day, I also am white, so I think there are fewer barriers to [orthopaedics because of] that … I connected really well with a physician the other day because we were both ski instructors at some point in time. And if you didn’t grow up with the money to go skiing, it’s a connection that you won’t be able to understand. And so I think I can kind of ‘talk the talk’ around some of these things; but I just kind of have to decide whether I want to opt into that” [M1_W_02]. Students said that holding a greater number of stereotypical identities (that is, identifying as an athletic white man from a privileged background versus identifying as an African American woman who is not interested in sports and who comes from a less privileged background) made it easier to have a sense of belonging in orthopaedics.

Students described themselves as being in a sort of cultural “in-group” when they experienced a sense of belonging in orthopaedics, whereas students described themselves as a cultural “out-group” when they did not experience a sense of belonging in orthopaedics. Therefore, given that students tended to associate having a sense of belonging with stereotype alignment, students who possessed a greater number of stereotypical identities tended to describe themselves in the “in-group,” and students possessing fewer (if any) stereotypical identities tend to describe themselves in the “out-group.”

In-Group and Out-Group Identities Influence Students’ Medical School Exposures

Interviewees subdivided their exposures to orthopaedic surgery in medical school into three categories: required coursework, optional “opt-in” experiences, and peer-to-peer interactions (Fig. 3). Because most exposures are “opt-in” in nature, students said they decided whether or not to engage in optional orthopaedic experiences based on their sense of belonging in the field. This is illustrated by a third-year medical student who identified as an out-group member: “When I was on my surgical clerkship, when they gave us their preferences to choose subspecialty surgical rotations, I guess I had a lot of assumptions about orthopaedics that maybe didn't fit with my character, so I never chose to do it” [M3_M_15]. This student said that his decision to not participate in an orthopaedic rotation was based on his lack of identity alignment rather than a lack of interest in the scope of orthopaedic practice. As such, the fact that he did not identify with preconceived stereotypes may have acted as a barrier to him pursuing “opt-in” exposures to orthopaedics in the medical school curriculum.

Fig. 3.

This chart represents medical students’ exposures to orthopaedic surgery during medical school.

Peer-to-peer interactions constituted an important aspect of specialty exposure. Many out-group students conveyed strong negative impressions about orthopaedic surgery based on their interactions with peers who were interested in the field. Participants said that peers interested in orthopaedics tended to be overly competitive people who have boisterous personalities: “I can’t think of anybody else that’s that obnoxious in my class about the field that they’re going into … I can’t think of any other specialty that I got that impression” [M3_W_11]. They described their peers’ perceived confidence in pursuing orthopaedics as being a deterrent to considering the field themselves: “[I feel like] they've wanted to do ortho ever since they started med school. That is what kind of resonates with me. And they’re just very ‘ortho or nothing.’ They just want to be an orthopaedic surgeon” [M1_M_14]. Moreover, out-group students felt that their peers who wanted to pursue orthopaedics had an exclusionary attitude, which reinforced their out-group identity. This highlights the importance of peer-to-peer exposure in group formation and suggests that in-group students themselves may act as a powerful deterrent for out-group students.

Out-Group Students Internalize a Lack of Fit in Orthopaedic Surgery

As out-group students make meaning of their orthopaedic surgery exposures, they said they tended to internalize a lack of fit, and subsequently tended to experience attrition of interest. Students who identified with the out-group remarked on exclusionary conversations, feeling ignored and unwelcome, and experiencing overt bias and inappropriate behavior when exposed to orthopaedics (Fig. 4). As a result, the out-group frequently did not pursue further opportunities to engage with the field after minimal exposure. For example, they chose not to complete an orthopaedic clerkship or attend orthopaedic interest group meetings. Importantly, they said that their avoidance of these activities was the result of exclusionary perceptions, stereotypes, and interactions, not necessarily the result of a lack of interest in the clinical practice of orthopaedics. Students in the out-group often reported experiencing a lack of identity alignment with orthopaedic exposures. Students remarked on their lack of culture fit, self-doubt, and lack of support and encouragement from residents and faculty, and a sense of sacrificing their core identity when considering an orthopaedic career (Table 2).

Fig. 4.

This chart represents how out-group students internalize and derive meaning from negative orthopaedic exposures. Of note, Anki is a web-based flashcard program, commonly used among medical students for studying.

Table 2.

Identity alignment, and lack thereof, for in-group and out-group members, respectively

Group	Theme	Representative quotes
In-group (reinforced identity alignment)	Culture fit	“I think a lot of people who are former college athletes gravitate towards it. And so there’s kind of that community that I feel I fit into. I’m always used to being around the ‘bros’ or guys, or just having an environment that people tease each other, people joke around. People have fun, but they also work hard. And we definitely have a crew of people like that who are interested in going to ortho right now at my school.” [M2_W_08]
		“Looking at not only our program here, but also just [orthopaedic] attendings at large ... I definitely think that my personality molds well with [them], as well as the way that they think, and the way that they carry themselves day to day.” [M3_M_13]
	Consistent encouragement	“No one has said, ‘you shouldn’t do this’ or ‘you can’t go into this’ or anything like that. Everyone’s been really supportive when I’ve said I want to go into orthopaedic surgery. So I’ve kind of had nothing but people encouraging me along the way.” [M3_M_16]
		“I think the people [in orthopaedics] are great. I’ve had nothing but really positive experiences with all of the orthopaedic surgeons at my school.” [M3_M_16]
Out-group (lack of identity alignment)	Lack of culture fit	“The impression I get about orthopaedic surgery is that it’s heavily male dominated. It’s a pretty white male field. And I don’t feel comfortable in that kind of environment because I’m not an athlete, and I’m not a big white guy.” [M1_W_03]
		“If someone was ... shy or very reserved, or didn’t like to participate too much, or kept to themselves, they might be intimidated by the fact that everyone’s very outgoing, [everyone’s] just gregarious in that sense. I guess they would feel out of place or may not want to be in [orthopaedic surgery].” [M2_M_09]
		“... Will I find people who are like me in [orthopaedics]? You know, you talk to residents [who say], ‘I love my coresidents, you find people, this and that.’ But would I really find my people? How much of my actual self would I be giving up in order to pursue it?” [M1_W_02]
	Self-doubt	“I know [orthopaedics] is a very competitive specialty. Knowing that, [I asked myself], ‘Would I? Could I cut it?’ I think I had some reservations around [this], whereas I didn’t necessarily see that with some of my male classmates, I would say.” [M1_W_02]
		“As a minority and as a female as well, I feel like there’s more for me to prove, and I have to be more vocal than my other peers.” [M2_W_19]
	Lack of support and encouragement	“I mean, kind of elephant in the room. It’s a very, very male profession. I am a female. And so I think that has always kind of been a little bit of a hang up. Coming into medical school as a woman, saying, ‘Oh I’m interested in orthopaedics,’ it’s oftentimes feedback from people [who say] ... ‘It’s not super female friendly,’ and what not. Whereas if you have someone who kind of fits the stereotype a little bit more, they only ever get positive feedback. They’re like, ‘Oh yeah, of course you want to be an orthopaedic surgeon.’ So just kind of a difference of feedback.” [M1_W_02]
		“I think that if there’s a male and a female student in a case, in my experience, the attending talks primarily to the male student in pointing out things [and] just generally walking through the case. And then when I’ve been the only female in the room, I think that happens a lot less, because there’s an assumption that there’s either less interest or less capability.” [M3_W_10]
	Sacrificing core identity	“How much of myself would I kind of have to give up, or hold my tongue on [to] do something that I like the science of, and that I like the procedures of?” [M1_W_02]
		“[There is] not a lot of research coming out of the orthopaedic surgery department about [racial] diversity or gender equality, or any anything related to that. So to me, that’s kind of giving me the impression that they don’t really care. And that’s not who I am. I really care about that.” [M1_W_03]

Quotes are denoted with the students’ year in medical school (M1- M4), gender (M = man, W = woman), and study ID number (01 to 23).

In-Group Students Internalize a Strong Fit in Orthopaedic Surgery

Participants who identified as members of the in-group described experiences that contrasted sharply with the out-group’s experiences. These students tended to describe a strong culture fit and received consistently positive feedback from residents and faculty when exposed to orthopaedics (Table 2). This in turn motivated them to seek further exposures, which augmented their identity alignment as part of the in-group. They reported that subsequent exposures reinforced their identity as an in-group member. An in-group student described his interactions during his orthopaedics clinical rotation, saying: “The residents were super kind. They do a lot of teaching too … [surgically] they’ll have me do as much as I am able to do whenever [I’ve worked with them] … I’ve had no bad experiences with them” [M3_M_16].

Importantly, in-group members tended to not express awareness of the barriers faced by individuals without in-group privilege. An in-group member described his surprise in hearing that his classmates who were women have different experiences than he did, stating: “I’ve also heard from some of my … female classmates that the reason that they’re dissuaded from orthopaedics is just the perceived culture of it. So, I guess it was kind of surprising to me to hear that” [M3_M_13]. In general, in-group and out-group students developed disparate impressions of the field as a result of their identity alignment, or lack thereof.

The Cyclical Nature of Belonging in Orthopaedics

Out-group students reported feeling that patterns of belonging and inclusion were deeply entrenched and cyclical; they said they felt that students who identified with the in-group made up the vast majority of students who ultimately pursued orthopaedics as a career, and this served to perpetually reinforce and strengthen the exclusive “in-group” nature of the field. Out-group students remarked on the deep-seated stereotypes about orthopaedics, their perception of the field’s complacency about diversity issues, and an assumed lack of acceptance for students with underrepresented identities (Table 3) as consequences of these reinforcing in-group cycles.

Table 3.

The compounding consequences of in-group cycles

Theme	Representative quotes
Deep-seated stereotypes	“It feels like the stereotype is very entrenched. And whether it’s the media or whatever, it feels like the stereotype is very strong around orthopaedic surgeons; whereas I don’t know if I could tell you as much [about] what the stereotype of a vascular surgeon is.” [M1_W_02]
	“When you search for an orthopaedic surgeon, just do a regular Google search, the majority of people you see will be a white male ... even sometimes when you look at residency pages, usually it’s mostly white males.” [M2_W_18]
Complacency about diversity	“There’s something about orthopaedics ... I think in general, compared to a lot of the other specialties that really focus on inequality and diversity in medicine, I feel like orthopaedic surgery hasn’t really been as vocal about it. So that kind of makes me feel like the people that are in orthopaedic surgery are not that interested, or maybe don’t feel like it’s a priority in the field.” [M1_W_03]
	I think, it would be an uphill battle because, I get this sense that a lot of orthopaedic surgery programs don’t have a very robust program to increase diversity. So if I were to go into orthopaedic surgery, I’d feel like I would be one of the first. These efforts to increase diversity and to prioritize it in this field, the infrastructure that is required for this, it hasn’t really been laid down yet.” [M1_W_02]
	“When I see other specialties that are highly competitive increasing their diversity and orthopaedics hasn’t ... I have to wonder if you’re not increasing your diversity, it sounds like a choice you’re making. A very obvious and even thoughtful choice. You see your colleagues doing it, so if you’re not doing it, then I’m left to believe you don’t want to.” [M3_W_23]
Assumed lack of acceptance	“Well, I think, because there’s a lack of diversity now, it may seem to some people that it’s not going to change. Or they may look at it and say there’s no place for me.” [M2_W_07]
	“It’s almost like a self-fulfilling prophecy, in a way ... with orthopaedics, [people say], ‘Oh, it’s all men. It’s all ‘bro-y’. I wouldn’t fit in, so I don’t want to even try to apply to that.’” [M2_W_06]

Quotes are denoted with the students’ year in medical school (M1- M4), gender (M = man, W = woman), and study ID number (01 to 23).

Most out-group members said they wanted to pursue other specialties, and commented specifically on the dearth of residents and mentors in orthopaedics with whom they identified. This is illustrated by a fourth-year medical student: “Hopefully on my own accord, I could change medicine and change [orthopaedics] from that perspective. But it got increasingly difficult as third and fourth year went on, because, you know the saying ‘death by a thousand cuts’: To never see anybody that looked like you or that could relate to you or that has the cultural or religious understanding of your background. And so that made me consider another specialty” [M4_W_05]. This student’s remarks highlight how these cycles have led to what she perceives to be an exclusionary in-group culture within orthopaedics.

Positive Sources of Identity Alignment for Out-Group Students Interested in Orthopaedic Careers

Despite an overall lack of belonging, some out-group members still expressed interest in orthopaedic careers. These students adopted a trailblazing attitude toward belonging-related obstacles, as illustrated by a first-year woman student: “There is some sort of allure behind [orthopaedics], like you’re told you can’t, so you want to. Not necessarily that I’ve been told that I can’t, but because it’s been less encouraged so it makes me want to do it ... There is a positive association with [the fact that] there aren’t that many women in it. That might make me want to do it even more to change the stereotype. I think that is something that I would be really interested in being involved with” [M1_W_02]. This trailblazing attitude was shared by students who held other underrepresented identities in orthopaedics, such as a second-year student who identified as a Hispanic man: “If anything, [the current state of diversity in orthopaedics] is encouraging because I feel like going into it would actually be a big help. Because you’re a part of the change that you want to see … You add one number to the big pool of people like us” [M2_M_09].

These students acknowledged that they were different from most of their peers who were interested in orthopaedics, but stated that they wanted to actively work against the perceived in-group culture through their presence in the field. These students described how residents and faculty members from diverse backgrounds positively impacted their own sense of belonging in orthopaedics by counteracting the perceived in-group culture. They also remarked on the importance of safe spaces for out-group students to discuss obstacles, having visible mentors with similar identities to them, and having in-group members engage in allyship behaviors (Table 4).

Table 4.

Positive identity-alignment modifiers for out-group members

Theme	Representative quotes
Space to discuss obstacles	“[The Perry Initiative] really made you feel like you could fit in in [orthopaedics] ... One thing where I go back and forth with on the topic of gender is, it would be great if we didn’t have to talk about it, but that’s not our reality now. How much of our time and effort do we want to spend talking about it versus, if we didn’t have to be addressing these things, how much more could we be accomplishing? So I think that the [Perry] program struck a good balance of both talking about it, but also just being like, ‘this is what it’s like being an orthopaedic surgeon,’ regardless of gender, which I really appreciated.” [M1_W_02]
	“[Nth Dimensions] created this community of people who could really express and identify with others regarding the lack of diversity in orthopaedics. And I think having that safe space to say, ‘I don’t feel like I belong in that residency,’ but I can hop on the phone for a Thursday monthly call and feel like I belong because there is a larger group of people nationwide.” [M4_W_05]
In-group allyship	“I think it’s [important to] have people that will really advocate for you in any given program, to have people ... that are very vocal about getting women interested in the field, and making sure that [they have] all the opportunities available to them.” [M1_W_01]
Mentorship	“I kept that connection strong with the mentor that I had at my Nth Dimension program site. He was an impactful mentor, you know, not just for orthopaedics ... [he] made efforts to be more religiously and culturally aware, and [learn] how that impacts providers and residents.” [M4_W_05]
Visible representation	“I think just meeting people that kind of didn’t fit whatever mold that I had thought about, or just what I perceived [orthopaedics] to be about, was positive. Not that I necessarily had a negative view of it, it just contrasted with what I had thought previously.” [M2_M_09]
	“I got really interested in woodworking and that sort of stuff as a kid because my uncle was a carpenter. But I think it would have been more powerful if it was my aunt that was the carpenter, you know what I mean? So I think like just with any mentor in any area, whether it’s carpentry or orthopaedics, or for anything else in academia ... I think having somebody you can really relate to, so you can see yourself in that person is really powerful.” [M1_W_01]
	“Finding people who look like you, visualizing [yourself] in that position ... [is] something that I guess I didn’t realize was very important. Seeing someone like me in that next step.” [M4_W_17]

Quotes are denoted with the students’ year in medical school (M1- M4), gender (M = man, W = woman), and study ID number (01 to 23).

Discussion

Orthopaedic surgery continues to lack diversity, despite efforts to recruit women and minority medical students during recent decades. Qualitative methodology gives us a tool to effectively understand the nuanced relationship between medical students’ sense of belonging and their perceptions of orthopaedic surgery. Through understanding this, we can identify the barriers to recruiting medical students from diverse backgrounds into orthopaedic careers more effectively. In our study, students identified with the in-group or out-group based on how closely their identities aligned with their preconceived notions about orthopaedic surgery. Importantly, there were compounding gender, race, and socioeconomic factors associated with orthopaedic stereotypes, and thus with in-group identification. Students who self-identified as members of the in-group reported feeling encouraged to seek more orthopaedic experiences, and that these further strengthened their identity alignment. Conversely, students who self-identified as members of the out-group predominantly reported not pursuing orthopaedic experiences and careers because they perceived a lack of fit, and often not because of a lack of interest in orthopaedic surgery.

Limitations

Although our study reached thematic saturation, with sufficient data to explore the role of belonging in orthopaedic surgery, we were not able to discern the nuanced experiences of students from every unique underrepresented identity. Our model provides a conceptual framework for understanding the formation of in-group and out-group perspectives, but it did not investigate specific subgroups’ experiences in orthopaedic surgery. Additional studies are needed to understand whether our model captures the experiences of specific subgroups, such as students of various socioeconomic backgrounds or those who identify as lesbian, gay, bisexual, trans, queer, intersex, and/or agender (LGBTQIA).

We recognize that our conceptual model is inadequate to fully explain which medical students ultimately become orthopaedic surgeons because other people, including medical school faculty and residency program directors, play a role in the match process. However, current data suggest that the primary problem is an insufficient number of women and minorities applying to the specialty, as opposed to not matching after interviewing for residency [20]. Regardless, this conceptual model of how students come to believe that they belong (or do not belong) illustrates why some might choose to pursue (or not pursue) careers in orthopaedic surgery based on their experiences and perceptions during medical school.

In addition, our study institutions were chosen to represent medical schools of different sizes and research rankings in the Midwest. Student experiences could differ in other regions of the United States, or in other regions of the world. However, because students who attend these Midwest medical schools come from all over the United States and the world, the themes that emerged in this study regarding belonging and fit in orthopaedic surgery likely reflect medical students’ beliefs and experiences more broadly. Our understanding of belonging and fit would benefit from more detailed examination, with a larger and more diverse global sample of medical students who may be considering an orthopaedic surgery career.

Is Belonging Important for Medical Students’ Interest in Orthopaedic Careers?

Our study suggests that perceived lack of belonging (that is, self-identifying as part of the out-group) may drive out-group students away from orthopaedic surgery careers. Students who identify with the out-group may be deterred from exploring and ultimately choosing to pursue orthopaedics because of a lack of personal identity alignment with the stereotypical white, heterosexual, athletic male persona. This may be compounded by negative interactions with in-group peers interested in orthopaedic surgery and lack of diverse representation in the field. Our findings are consistent with prior work examining the concept of social belonging uncertainty, which can be thought of as the internal fear that underrepresented students carry about whether “people like me” belong in certain environments [21, 36]. Our findings suggest that a medical student’s interest or disinterest in orthopaedic surgery is not solely based on clinical factors related to the practice of orthopaedic surgery, but rather on a student’s sense of alignment with preconceived notions about and stereotypes of orthopaedic surgeons.

Further study is needed to investigate whether medical school programs, faculty advisors, and peers can help counteract out-group identification through interventions aimed to increase diverse students’ sense of belonging. If successful, these interventions could contribute to promoting greater inclusion of underrepresented groups in orthopaedic surgery. Several studies have demonstrated the impact of social fit and belonging on the academic performance of women and underrepresented students in college settings, and have demonstrated how social belonging interventions can improve integration of traditionally underrepresented students into school communities [36, 38]. Social belonging interventions aim to provide students a way to “develop a nonpejorative narrative for understanding worries about and challenges to belonging” [39]. One example of a social belonging intervention is using written stories from diverse older students to convey to younger students that worries about belonging are normal, common, and improve with time. Students then discuss and reflect upon these themes in small group settings. The goal of this exercise is to provide students with a new lens to interpret potentially negative or isolating experiences [39].

Understanding the phenomenon of belonging is critically important to recruiting diverse medical students into orthopaedic surgery. The concept of social belonging is described as the “sense of having positive relationships with others” [37]. Strong evidence supports the importance of social belonging in college education and surgical training [29, 36, 38]. Given the evidence for the importance of belonging [29, 36, 38], the question then becomes: How can we cultivate a sense of belonging in orthopaedics for students with a myriad of underrepresented identities? With knowledge of the factors that influence a sense of belonging, clinicians and academic orthopaedic departments can focus on interventions that will lead to a more diverse pool of medical students interested in orthopaedic surgery.

Proposed Solutions Based on the Evidence

We propose several targeted interventions at various stages of our model to cultivate a sense of belonging in orthopaedic surgery for medical students with underrepresented identities. These include addressing preconceived notions and stereotypes about orthopaedics, exposing medical students to positive experiences during orthopaedic trainings, and cultivating identity alignment for students from diverse backgrounds (Table 5). Prior research supports the effectiveness of targeted interventions; for example, department-wide diversity, equity, and inclusion assessments to understand institutional barriers [13, 41]; increased diversity and inclusion-centered programming for medical students [17, 19]; and creating opportunities for students to discuss belonging-related barriers [40, 42]. These recommendations may mitigate the challenges identified in this paper and should be explored in future studies.

Table 5.

Our proposed solutions and interventions within the model framework

Framework component-based intervention	Proposed solutions
Preconceived notions and stereotypes	Conduct a comprehensive department-wide DEI assessment [41]. This includes an assessment of department culture, collecting data regarding representation in the residency program, representation of faculty at every promotion level, time to promotion, compensation, equity in department policy (for example, parental leave), inclusiveness of physical spaces (such as photographs or portraits on the walls and gender-neutral bathrooms), and the diversity of lectureship and grand-rounds speakers [9,13]. Conduct focus groups to understand institution-specific out-group barriers.
	Adopt best practices among orthopaedic departments nationally. Establish a culture of collaboration and accountability between orthopaedic departments. Lean on other specialties for best practices, interventions, and implementation ideas.
	Use the findings from the comprehensive DEI assessment to create a DEI scorecard. This involves defining specific DEI objectives, devising tactics for meeting these objectives, and setting metrics for measuring progress. Reassess progress at least annually. Transparently report data to your department members, colleagues, and prospective students along with plans for improvement [41].
Exposure to orthopaedics	Increase the number of contact points with medical students, particularly early in their training. This includes getting involved with the musculoskeletal curriculum and participating in the anatomy laboratory. Offer and encourage students to participate in an orthopaedic surgery clerkship. Obtain regular feedback from students about their clerkship experiences, including feedback on issues related to belonging.
	Consider the inclusivity of the orthopaedic surgery interest group. Help medical student leaders emphasize inclusive values and diversify the group’s leadership.
	Increase early exposure to orthopaedics for students with underrepresented identities. Create intentional programming partnerships with college and medical student affinity organizations such as the Minority Association of Premedical Students, Student National Medical Association, Latino Medical Student Association, Asian Pacific American Medical Student Association, Building the Next Generation of Academic Physicians, the American Medical Women's Association, and the Association of Women Surgeons.
Lack of identity alignment	Increase the visibility of orthopaedic faculty from diverse backgrounds. Support faculty in roles that interface with medical students and residents and compensate faculty for their efforts.
	Create space to talk about out-group barriers. This includes hosting Perry Initiative programming and encouraging students to participate in Nth Dimensions programming [17, 19]. Encourage students to attend national society meetings, such as through Ruth Jackson Orthopaedic Society scholarships for medical students to attend the American Academy of Orthopaedic Surgeons meeting. Consider longitudinal department-sponsored mentorship programs between faculty and students from nonstereotypical backgrounds. Appropriately compensate faculty mentors for their time and effort spent doing mentorship activities. Consider a department-funded dinner series for students and faculty to talk about barriers and how to overcome them.
	Make a conscious effort to serve as a mentor, sponsor, and ally for students, regardless of background [18, 25].

People with underrepresented identities include women and gender minorities, individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, and/or agender (LGBTQIA); racial or ethnic groups that are underrepresented in medicine; and individuals from socioeconomically disadvantaged backgrounds or who are first-generation college graduates; DEI = diversity, equity, and inclusion.

Conclusion

We found that medical students’ sense of belonging in orthopaedic surgery is based on preconceived stereotypes about orthopaedics compounded by their experiences in medical school. Moreover, the extent to which students perceive identity alignment with these stereotypes impacts their interest in orthopaedic surgery. Focused interventions are needed to interrupt the current cycle in which students with underrepresented identities are deterred from pursuing orthopaedic careers because of their perceived lack of belonging. It is especially important that departments associated with medical schools address deeply entrenched stereotypes about orthopaedic surgeons. To accomplish this, we suggest actively providing students with opportunities to interact with orthopaedic departments, coupled with specific efforts to promote an inclusive culture. Positive experiences and purposeful inclusion can combat out-group identity formation, thereby increasing all students’ interest in the field. By directly addressing the obstacles to belonging elucidated in our model, these interventions can help cultivate an environment of inclusion that will ultimately help promote diversity in orthopaedic surgery.