CORR Insights®: What is the Trend in Representation of Women and Under-represented Minorities in Orthopaedic Surgery Residency?

Where Are We Now?

Despite accounting for nearly 20% of medical students and 13% of applicants, underrepresented minorities account for only 6% to 8% of orthopaedic surgery residents [3, 5]. Similarly, women represent approximately half of medical students and a third of trainees in surgical subspecialties, but only 14% to 16% of orthopaedic surgery residents, with an annual growth rate of 0.6% [5, 6].

The disparities are even more glaring within orthopaedic subspecialties. Only 3% of surgeons in adult reconstruction and spine surgery are women [2]. Women account for 6% to 9% of practicing orthopaedic surgeons and fewer than 4% of orthopaedic surgeons identify as Black, Hispanic, or Native American [2, 3, 5, 6, 12].

Applicants who are underrepresented minorities match at a lower rate than majority groups and the representation of women within professional societies remains low [2, 12]. There is also a disproportionately low number of women and underrepresented minorities who hold positions as full professors of orthopaedic surgery [4, 7].

This study by Haffner and colleagues [5] used the Accreditation Council for Graduate Medical Education database to determine the proportions of women and underrepresented minorities in seven different surgical specialties: orthopaedic surgery, neurosurgery, ophthalmology, otolaryngology, plastic surgery, general surgery, and urology for the 2011 to 2012 through 2019 to 2020 academic years. They also used linear regression analysis to predict growth rates [5]. Among the seven subspecialties evaluated in this study, orthopaedic surgery had the lowest representation of women residents every year. These data reinforce that orthopaedic surgery is not succeeding in efforts to improve diversity while other subspecialties, like general surgery, are finding ways to close that gap.

Based on their findings, programs should facilitate early exposure to orthopaedics by advocating for mandatory clerkship rotations, and departments should actively recruit new faculty members from nonmajority groups. They should acknowledge that current practices for evaluating applicants have not had a meaningful impact on diversity and should reevaluate metrics that may inadvertently screen out more women or underrepresented minorities than applicants from majority groups [12]. They should also ensure that research does not skew toward investigating conditions that disproportionately impact the majority groups.

Where Do We Need To Go?

Identifying the most important barriers to attracting and maintaining a diverse pool of trainees is critical. Barriers will exist at every branch point on the path to becoming an orthopaedic surgeon, and we must look to organizations that have had success in overcoming similar situations for guidance.

Two successful examples are the Perry Initiative and Nth Dimensions, organizations that target women and minority students from high school to graduate levels to foster interest in orthopaedic surgery. By providing role models and generating interest in the specialty, these students have the opportunity to make themselves competitive applicants early in the process. The resources that these programs have is limited, and additional support from national organizations including the American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and subspecialty organizations would expand their reach. Also, because many medical students matriculate with preexisting interest in certain specialties within medicine, expanding outreach efforts and mentoring at the undergraduate level may be impactful.

At the faculty and leadership level, we need to better understand the systematic biases that limit the advancement of women and underrepresented minority surgeons in practice. Diversity within leadership positions of many national organizations is also limited [2, 7]. Interestingly, research investigating the performance of large companies worldwide has demonstrated that gender and ethnic diversity among leadership improves company value and profitability [8]. We also have the potential to improve our own performance by building more diverse teams.

These changes do not occur passively, and there are real consequences to neglecting them. Healthcare disparities are rampant in our society, and a reasonable first step to combating them is by making an active effort to include the thoughts and experiences of the individuals who are most impacted by them [11].

Unfortunately, orthopaedic surgery continues to carry a reputation that may discourage women and minority applicants. As a clerkship student, I was open about my interest in orthopaedics. A senior resident told me to reconsider. I would be hated by nurses and OR staff because I was smart and female, the senior resident told me. An attending told me to decide whether I wanted a family before committing to that path. I found these comments easy to ignore because I was sure that orthopaedics was right for me, but I could see how this may dissuade a student who was less certain.

How Do We Get There?

Currently, the students who will be exposed to orthopaedics through elective rotations will be those with prior interest. Engaging with medical students during the preclinical and clerkship phases of their education may spark interest in those who hadn’t considered orthopaedics. We can take a more active role in preclinical education by teaching physical exam sessions, anatomy labs, and basic procedural skills workshops. Integrating orthopaedic surgery into the required general surgery clerkship may also provide the necessary exposure to dispel some of the myths that are propagated by those outside of the field. A mandatory clerkship rotation on musculoskeletal medicine has been shown to increase the percentage of women and underrepresented minority students applying into orthopaedic surgery [9].

Recruiting applicants who are female or underrepresented minorities is an important step, but we must also demonstrate a commitment to diversity in the faculty that we recruit. The Rooney Rule—a policy in the NFL that requires at least one underrepresented minority be interviewed for head coaching positions—could be applied to ensure a more diverse pool of candidates, but creating conditions that permit diversity is not sufficient [5, 6]. More important is inclusion, which involves promoting them within academia and professional societies, supporting policies specific to the needs of those groups, and serving as their mentors [1]. Mission statements from departments reflect our values and should establish tangible goals that address diversity initiatives. Besides recruiting women and underrepresented minority residents and faculty, this may include encouraging participation in societies such as the Ruth Jackson Orthopaedic Society and J. Robert Gladden Orthopaedic Society, partnering with community clinics, or funding research on health disparities and issues that impact nonmajority groups.

Frankly, we don’t need additional studies to justify the inclusion of people from a diverse set of backgrounds and experiences [10]. We need to accept that the responsibility of attracting a diverse workforce should not be borne by the few that represent that population, it requires the acknowledgement that diversity of thought and background improves our performance and patient outcomes, which is our goal. We are not on the path to meaningful change—at the current pace, it will take over 200 years to reach gender parity with the overall medical profession [2]. Like surgical training, change is an active and intentional process with hurdles along the way. It is neither straightforward nor rapid, but we are capable of driving this change on both an institutional and national level. We just need to value it enough to do it.