Diversity, Equality and Inclusion in Orthopaedics

Since the 1970s the percentage of women entering medicine has steadily increased, and currently 51% of matriculating medical students are female. The number of females entering surgical specialties has also steadily increased. While the many surgical subspecialties including neurosurgery, plastic surgery, urology, and others have seen continued growth of female surgeons, orthopaedics unfortunately has not seen the same growth.^1,2,3 Orthopaedics has only seen a 2-3% increase since 1990.

Overall, orthopaedic surgery ranks last (5.8%) in the percentage of practicing female physicians, and that percentage has not dramatically changed when discussing training programs where it continues to rank last in the percentage of female residents (16% as of 2020) and underrepresented minorities (URMs)(7.7% in 2020).^2,4,5,6 At the current rate of 3% growth per year, it would take 217 years to reach parity in orthopaedics.⁶ This reflects the lack of growth in diversity.

Of concern, recent work has identified the American Shoulder and Elbow Surgery society (ASES) as having one of the lowest percentages of female members.⁷ Only the scoliosis research society, the knee society, cervical spine research society, and hip society rank lower. Clearly, there is much room for improvement for inclusion with Orthopaedics as well as within our specialty. While there are many factors that influence the advancement of diversity, a few important topics will be discussed.

Why Do We Need to Improve Diversity? 

An abundance of literature demonstrates underrepresented minorities have worse outcomes compared to Caucasian patients even when accounting for socio-economic factors. Additionally, patients want to be treated by those who look like them as patient satisfaction improves with communication among people who share similar social, cultural, and linguistic experiences.²

Finally, recent evidence suggests that patients who are treated by physicians of the same race, ethnicity, cultural background, or gender feel more comfortable with their care and tend to have better outcomes.⁸ With 12.4% of the U.S. population identifying as African American and 51% of the population being women, clearly the orthopaedic community does not reflect the current population.

Ways to Improve Diversity 

Bias (explicit, implicit)

Bias can be both implicit and explicit through a variety of ways including personal interactions, institutional cultures, recruitment and hiring processes, as well as professional evaluation processes.^9,10 All of these processes have the potential to subtly disadvantage underrepresented minorities and women.

Explicit biases are demonstrated by those who believe that women should simply not be orthopaedic surgeons because they do not possess the strength, intelligence, temperament, or other characteristics. Those are often easily identified within society. However, implicit bias, which is likely much more prevalent but difficult to identify, has been defined as a reflection of unconscious attitudes or stereotypes that affect individual decisions and actions. Correction of implicit bias centers on self-awareness of the problem and a desire for change. To improve diversity, leaders must first recognize that bias exists (often within themselves as well) and then have the desire to eliminate it. Only then can leaders work to gain “buy-in” from fellow members (partners, colleagues, and faculty).

To achieve this, bias literacy (the uncovering, defining, and understanding of implicit bias so it may be made explicit) is a necessity. The Harvard Implicit Association Tests (IAT) is a free online tool used to detect and measure implicit bias. This test should be required of all participants to evaluate bias among team members.

The hiring process is just one example of how implicit bias perpetuates the lack of diversity within our profession. Within the recruitment and evaluation process, bias tends to flourish when such processes are unstructured or informal. Additionally, evidence suggests that interviewers preferred men, Caucasian-sounding names, a lighter skin tone, taller individuals, and personality traits most associated as male attributes. To counteract this implicit bias, it has been recommended that during the recruiting process committees establish a specific set of criteria and commit to the value of credentials before evaluating individual applicants.

Mentors and Advocates 

Mentors and advocates are critical to the development and advancement of surgeons, especially in academic medicine.⁹ While they are often used interchangeably, and can be the same person, they are in fact two separate qualities.

A mentor is an individual who provides guidance through the process of navigating a career path from past experiences of the mentor. An advocate actively creates opportunities for promotion and progression to leadership positions are more closely tied to the concepts of advocacy and sponsorship than to mentorship.

The difference between these roles is clear: a mentor helps one think through the process of navigating his or her career, whereas an advocate is a person with influence and who creates opportunities for others toward promotion and career advancement. Women and URMs are in need of more mentors and advocates in order to improve diversity within our profession. Increasing exposure of women and URM surgeons on podiums and major speaking roles at conferences, meetings, and teaching events is just one way an advocate can help with progress.

When an audience sees a diverse faculty at events it helps cultivate the principle of being a diverse organization. It should be noted that not all mentors or advocates need to be of the same race or gender. Especially in the current state with the limited number of active female and URM surgeons, strong male leaders can provide both mentorship and act as advocates. My personal experience has seen several male orthopaedic colleagues provide crucial mentorship as well as become an advocate for my professional development.

Several organizations have been created to help address this issue (Perry Initiative, Ruth Jackson Society, J Robert Gladden Society, Orthopaedic Diversity Leadership Consortium, Nth Dimension), and evidence suggests that these organizations are making an impact. URM and women who attended a medical school at an institution with high URM and female representation on the faculty and residency were more likely to apply to orthopaedics. However, more support and recognition are necessary to continue to diversify our profession. It has also been identified that early exposure to orthopaedics has increased awareness of the specialty to women and URMs.

Many subspecialities have recently organized Diversity, Equality, and Inclusion (DEI) committees. ASES leadership organized a DEI subcommittee, and with executive board mentorship and advocacy our committee has accomplished several impressive achievements within only a few years. The list of achievements includes sponsorship of a Nth dimension summer intern in shoulder/elbow, the creation of an ASES scholars program introducing local medical students to the field of shoulder and elbow surgery, and junior resident scholarships for ASES/AAOS shoulder/elbow courses, and a medical student/resident webinar to expose the specialty of shoulder and elbow surgery to a younger group of future physicians.

The recent increased recognition regarding the need for diversity is encouraging. While recent progress is promising, there needs to be a continued long-term effort to change the culture of diversity within our specialty and orthopaedics as a whole. Without a sustained focused goal of change in culture, the progress made to date is at risk for failure.

Finally, the topic of diversity in orthopaedics should not be limited to surgeons. Diversity within our industry as well as support from staff should also be targeted. As a female surgeon, I want to also work and collaborate with companies who have demonstrated a clear dedication for improving diversity within our workforce.

The mentioned topics are just a small subset of many additional factors not mentioned in this blog post, but they are meant as a possible catalyst for discussion as well as achievable actionable items. While the overall goal is to increase membership of women and URMs, we also must be cognizant of these individuals’ qualifications and if they can uphold the standards of professional care that should be expected of every orthopaedic surgeon.