Orthopedics

Feature Article 

Pioneer Female Orthopedic Surgeons as Role Models

Olga D. Savvidou, MD; Frantzeska Zampeli, MD; Thekla Antoniadou, MD; Annelies Van Beeck, MD; Panayiotis J. Papagelopoulos, MD, DSc, FACS

Abstract

Maud Forrester-Brown in the United Kingdom (1921), Marika Daniilidou in Greece (1932), Ruth Jackson in the United States (1932), Loris Figgins in Australia (1957), and Evalina Burger in South Africa (1993) all chose to specialize in orthopedics. Although there are dynamic female leaders in orthopedic surgery, the field continues to present obstacles to women. Role models, mentors, and exposure to the field have been lacking for women. Although improvements have occurred in the past few decades, further changes are necessary to attract, develop, and retain qualified female candidates. [Orthopedics. 20xx; XX(X):xx–xx.]

Abstract

Maud Forrester-Brown in the United Kingdom (1921), Marika Daniilidou in Greece (1932), Ruth Jackson in the United States (1932), Loris Figgins in Australia (1957), and Evalina Burger in South Africa (1993) all chose to specialize in orthopedics. Although there are dynamic female leaders in orthopedic surgery, the field continues to present obstacles to women. Role models, mentors, and exposure to the field have been lacking for women. Although improvements have occurred in the past few decades, further changes are necessary to attract, develop, and retain qualified female candidates. [Orthopedics. 20xx; XX(X):xx–xx.]

The percentage of female medical students began to increase in the 1970s. Between 1965 and 1974, the opening of 25 new US medical schools led to an increase in the number of medical students and faculty, and many of these appointments went to women.1 The number of women applying for residency in surgical specialties has increased, and women currently constitute 30% of the general surgery resident population.2

Given these increases, it would be expected that the number of women in orthopedic residency programs would have also increased. However, a relatively small number of women are currently practicing orthopedics. Among female residents, less than 1% choose orthopedics, and this has not changed in the past 20 years.3 Although it is often assumed that issues related to lifestyle are the driving force behind career selection, studies have indicated that mentoring and the presence of role models have the strongest influence.2,4

This article discusses some pioneer female orthopedic surgeons in the United Kingdom, Greece, the United States, Australia, and South Africa. Although from different continents, they have many similarities. All encountered difficulties during their medical career, but they persisted in order to reach their goal. They illustrate not only the career opportunities for women in orthopedics but also that women can reach the top of the field and have significant accomplishments.

Maud Forrester-Brown, MD

Maud Forrester-Brown, MD, was one of the pioneers of orthopedic surgery in the United Kingdom in the early 20th century. She was the first female orthopedic surgeon in the United Kingdom.5 She was born in North London in 1885. Dr Forrester-Brown joined the British Orthopaedic Association in 1921. In 1925, she was appointed resident surgeon at Bath and Wessex Children's Orthopaedic Hospital. She had significant achievements during the period of World War II. She was an active member of the British Orthopaedic Association, the Orthopaedic Section of the Royal Society of Medicine, and the Royal College of Surgeons. Dr ForresterBrown joined the International Society for Orthopaedic and Trauma Surgery and was elected an emeritus member. She was also a member of the Medical Women's International Association.

Dr Forrester-Brown worked consistently in the area of congenital skeletal diseases, publishing on the diagnosis and treatment of deformities in infancy and early childhood and on paralysis in children. Through her experience, she established children's hospitals in 3 counties in England.5 Although her contributions would have been appropriate, she was not awarded an honorary fellowship of the Royal College of Surgeons, perhaps because she did not have a surgical fellowship, which was normal practice for a surgeon. Further, she was not mentioned in an honors list, and she does not appear in the Dictionary of National Biography.5 She died in 1970.

Marika Daniilidou, MD

Another pioneer female orthopedic surgeon in Europe was Marika Daniilidou, MD (Figure 1). She was born on December 27, 1902, in Prokopion, of Asia Minor, to Greek parents. In 1922, after the destruction of Smyrna and the population exchange between Turkey and Greece, she and her family moved to Athens, Greece. She was accepted to the medical school of Berlin University in Germany, graduating in 1928. In 1928, she passed the state examination of the Prussian Ministry of People's Welfare. She received the certification for medical practice from the Medical School of National and Kapodistrian University of Athens on April 9, 1928.

Marika Daniilidou, MD. [Photograph courtesy of Hellenic Association of Orthopaedic Surgery and Traumatology (HAOST).]

Figure 1:

Marika Daniilidou, MD. [Photograph courtesy of Hellenic Association of Orthopaedic Surgery and Traumatology (HAOST).]

From 1928 to 1929, Dr Daniilidou worked as a resident in orthopedics in the then recently established orthopedic department of Berlin University. This was under the supervision of Professor Hermann Gocht, founder of the Orthopedic Department at Charite Berlin University Hospital. In 1929, she completed her PhD thesis at Berlin University. She worked at the Anatomy Institute of Halle University from 1929 to 1930 under the supervision of the director of the institute, Professor Hermann Stieve. From 1930 to 1931, Dr Daniilidou attended the Institute for vertebrate tuberculosis “Red Cross Klotzsche Dresden” and the Municipal Children's Hospital “Institute für wirbeltuberkulose v roten Kreuz Klotzsche Dresden and the Städtische Kinderklinik” in Dresden. In 1932, she moved to Halle, 170 km southwest of Berlin, and worked in the Department of Orthopaedic Surgery at Halle “Klinik Orthopadische Unfallschirurgie Halle.” In 1933 and 1934, she worked in the Department of Paediatric Orthopaedics at the Universitats Kinderklinik, Halle.

The Nazi regime's attaining power marked the end of numerous rights for women in Germany. In 1933, school programs for women were changed, notably with the goal of discouraging women from pursuing university studies. Women had a limited right to training, which mostly revolved around domestic tasks, and over time they were restricted from teaching in universities, having medical professions, and serving in political positions.6

In 1935, Dr Daniilidou returned to Athens and became the first female orthopedic surgeon certified by the Athens School of Medicine and the Hellenic State. She joined the Athens Medical Association in 1937 and started practicing as an orthopedic surgeon.6 In 1938, the Orthopaedic Specialty Board Examinations were officially established in Greece.

In April 1941, the Nazis occupied Greece. There was great starvation in Athens, and the Athens Medical Association developed 65 emergency care shelters. Between 1941 and 1944, many physicians lost their lives to the Nazis in Athens by either execution or starvation. On May 5, 1943, Dr Daniilidou joined the emergency care shelters along with other volunteer physicians.

After the liberation of Greece from the Nazis, orthopedic surgeons had an essential role to play in Athens due to the increased incidence of trauma, tuberculosis, and poliomyelitis.7 However, there were still few certified orthopedic surgeons.

On November 9, 1947, 22 orthopedic surgeons, most of them with double specialty certification (surgery and orthopedics), established the Hellenic Association of Orthopaedic Surgery and Traumatology. Dr Daniilidou was the only female orthopedic surgeon among them. She would be exceptionally active in all of the scientific activities of the Hellenic Association of Orthopaedic Surgery and Traumatology for years to come.

Dr Daniilidou practiced orthopedic surgery at the Social Insurance Institute Clinic until she retired in 1967.8 However, she continued participating in the educational activities of the Hellenic Association of Orthopaedic Surgery and Traumatology until the late 1970s.9

Ruth Jackson, MD

In the United States, Ruth Jackson was born on December 13, 1902, the same year as Dr Daniilidou, near Scranton, Iowa (Figure 2). She moved to Dallas, Texas, when she was 14 years old.10,11 She married but divorced 2 years later to concentrate on her work.11 After high school, she planned to enroll in premedical studies at the University of Texas at Austin. When her father disapproved of this, she became a sociology major. However, she changed her major to premedicine before graduating in 1924.10 She attained a bachelor's degree in economics and sociology from the University of Texas at Austin. In 1928, she graduated 8th in her class from Baylor College of Medicine, being 1 of 4 women in the class of more than 100 medical students. During her training as a medical student, she was not allowed to examine men. Further, she was told at orientation that the female students would need to achieve grades 10 points higher than those of the male students to graduate with “equal standing.”10

Ruth Jackson, MD. [Reprinted with permission from Manring M, Calhoun J. Biographical sketch: Ruth Jackson, MD, FACS 1902–1994. Clin Orthop Relat Res. 2010;468(7). https://journals.lww.com/clinorthop]

Figure 2:

Ruth Jackson, MD. [Reprinted with permission from Manring M, Calhoun J. Biographical sketch: Ruth Jackson, MD, FACS 1902–1994. Clin Orthop Relat Res. 2010;468(7). https://journals.lww.com/clinorthop]

After graduating, she intended to start residency and internship in general surgery. However, general surgery internships were not accessible to women at the time. In 1928, she started a rotating internship at Worcester Massachusetts Memorial Hospital. In 1930, she continued her residency in orthopedics under the supervision of Dr Arthur Steindler at the University of Iowa. After completing her residency in orthopedics at Worcester, she served as a resident physician at the Scottish Rite Hospital for Crippled Children in Dallas, Texas, from 1931 to 1932.

In 1932. Dr Jackson opened her private office in Dallas.10 The following year, the American Academy of Orthopaedic Surgeons (AAOS) was founded, allowing male orthopedic surgeons to join without examination. As a woman, Dr Jackson could only become a member by passing the examination. She passed the board examination in 1937, becoming the first woman not only certified by the American Board of Orthopaedic Surgery but also admitted to the AAOS. She started working at Baylor University Hospital in 1939. Dr Jackson became chief of the non-school orthopedic service at Parkland Hospital and established the first orthopedic residency at Parkland Hospital. She established her own private clinic in Dallas in 1945, practicing orthopedics for the next 38 years.11–13 Dr Jackson was one of the founders of the Texas Orthopaedic Association in 1936.13

Although she stopped performing surgery in 1974, Dr Jackson continued to treat patients until 1989.11 She wrote the book The Cervical Syndrome14 based on her experiences treating more than 15,000 neck injuries, and she had more than 25 publications in medical journals. Dr Jackson was an expert on problems of the foot, ankle, and cervical spine. She invented the Jackson Cervi-Pillow for patients with whiplash injuries.11,12,15,16 In 1950, she was appointed to the Advisory Committee on Services for Crippled Children by the Secretary of Labor, Frances Perkins. In 1983, the Ruth Jackson Orthopaedic Society was founded in Rosemont, Illinois. It is the oldest support and networking group for female orthopedic surgeons, residents, fellows, and medical students, has a mentoring scheme, and works with the AAOS.10,12,17 Dr Jackson finally retired from clinical practice in 1989, at the age of 87 years.

Loris Figgins, MD

Loris Figgins, MD, was the first female orthopedic surgeon in Australia. She began her studies at Melbourne University in 1945. After graduating, she worked in the Pathology Department of Queen Victoria Hospital before obtaining a 12-month internship at the Frankston Orthopaedic Section of the Royal Children's Hospital. There she became number 13 in a clinical group with 12 men.

Dr Figgins next worked at Austin Hospital for 7 years, reestablishing an orthopedic unit.18 A patient with spine tuberculosis who was admitted to Austin Hospital at 2 years old mentioned in his book19 that he was saved from paraplegia by a young medical officer in the hospital's orthopedic unit—Dr Loris Figgins. He wrote that Dr Figgins had happened upon a treatment by chance in 1952 while caring for a 4-year-old boy with tuberculosis and hip disease. She gave him a blood transfusion that immediately improved his condition and led to his signs of infection subsiding 6 weeks later. Although Dr Figgins was not sure why this happened, suggesting a possible role for antibodies that were administered with the transfusion, she successfully treated several other patients and had brought the treatment with her to Austin.19

Dr Figgins performed research under the guidance of University of Melbourne professors R. Douglas Wright and Edgar King. She recalled, “There was much criticism of both the treatment and my right to have an opinion … I felt so frustrated by their bigotry … I concluded that it was best to go overseas to the College of Surgeons in England and obtain their much sought-after qualification.”18

Dr Figgins went to the United Kingdom in the 1960s. After 3 years, she returned to Australia, spending the rest of her career working on behalf of victims of traffic accidents and industrial trauma. Although she was proud of her achievements at Austin, she felt that no one had tried to further improve her ground-breaking work.

Evalina Burger, MB ChB, MMed

Evalina Burger, MB ChB, MMed, was the first orthopedic surgeon from South Africa (Figure 3). She is currently the chair of the Department of Orthopedics at the University of Colorado School of Medicine. She is an expert spine surgeon and is considered by her peers to be one of the best physicians in the country. She graduated with a medical degree, MB ChB, from the University of the Orange Free State in South Africa in 1984. She earned a graduate degree from the University of Pretoria in 1993. In 2000, she became the first female orthopedic surgeon from South Africa and the third woman to receive the American-British-Canadian Traveling Fellowship, awarded to highly accomplished young surgeons from English-speaking countries. Prior to joining the University of Colorado, Dr Burger was an associate professor at Louisiana State University Health Sciences Center in New Orleans from 2001 to 2006.

Evalina Burger, MB ChB, MMEd. [Photograph courtesy of Dr Burger.]

Figure 3:

Evalina Burger, MB ChB, MMEd. [Photograph courtesy of Dr Burger.]

Currently, in addition to being a highly productive surgeon, Dr Burger is an active investigator and educator, having written several peer-reviewed publications and book chapters. After a national search, she was selected to succeed Robert D'Ambrosia, MD, at the University of Colorado School of Medicine. The Department of Orthopedics has more than 110 faculty members. She hopes to grow the department into a global destination for health care excellence. She has served as vice chair of clinical affairs in the Department of Orthopedics since 2008, working on clinical service development, strategic business planning, and the enhancement of the quality of patient care. John J. Reilly, Jr, MD, dean of the School of Medicine, considers her a “talented surgeon and a dedicated colleague … who successfully treats patients from all walks of life while efficiently managing the need for high-quality and efficient care in an academic setting.”20

Two Additional Women of Note

Mary O'Connor, MD, an orthopedic oncologist, was appointed chair of the Department of Orthopedic Surgery at the Mayo Clinic in Jacksonville, Florida, in 2005 (Figure 4). In 2015, Dr O'Connor became the inaugural director of the Center for Musculoskeletal Care at Yale School of Medicine and Yale New Haven Health. She was the first female member of the Musculoskeletal Tumor Society, the International Society of Limb Salvage, the American Association of Hip and Knee Surgeons, and The Knee Society. She has served as president of the Association of Bone and Joint Surgeons, the American Association of Hip and Knee Surgeons, the International Society of Limb Salvage, the Musculoskeletal Tumor Society, and the Ruth Jackson Orthopaedic Society.21

Mary O 'Connor, MD. [Photograph courtesy of Dr O'Connor.]

Figure 4:

Mary O 'Connor, MD. [Photograph courtesy of Dr O'Connor.]

In 2018, 80 years after Ruth Jackson joined the AAOS, Kristy L. Weber, MD, became the first female vice president of the AAOS (Figure 5). She is currently the first female president of the AAOS.22

Kristy L. Weber, MD. [Photograph courtesy of Dr Weber.]

Figure 5:

Kristy L. Weber, MD. [Photograph courtesy of Dr Weber.]

Discussion

Since 1847, when Elizabeth Blackwell, the first woman to receive a medical degree in the United States, was accepted as a medical student, the number of women in medical school has increased. Currently, women constitute 49% of the students in US medical schools. According to a report from the Association of American Medical Colleges, women make up 38% of the full-time academic medicine faculty. However, only 13% of female faculty are professors, compared with 30% of male faculty. Only 15% of department chairs and 16% of deans are women. These statistics have improved only slightly during the past decade.23,24

In the United States, the paucity of women in orthopedic surgery continues despite the increasing representation of women in medical school and in other traditionally male-dominated subspecialties, such as general surgery, obstetrics, ophthalmology, neurosurgery, urology, and otolaryngology. Although women represent 13% of orthopedic surgery residents, the results of an Association of American Medical Colleges survey are more disappointing, revealing that only 4% of orthopedic surgeons are women.3,25,26

In Europe, the gender gap remains profound regarding practicing orthopedic surgery. In the United Kingdom in 2013, although 57% of physicians in training were women, this volume of women was not reflected in surgical specialties. Whereas 22% of pediatric surgeons are women, just 10% of surgeons on the specialist register are women and only 4% of specialists work in trauma and orthopedic surgery.27

In Greece, few women are in academic medicine. Although data from the Aristotle University of Thessaloniki—the second largest medical school in Greece—for the period from 2000 to 2010 showed a male to female medical student ratio of 1:1 (2178 male and 2125 female), the numbers of women in academic positions in medicine are not as encouraging.28 Based on data from the Hellenic Society of Female University Faculty for 2016, 32% of academic faculty in the Medical School of the National and Kapodistrian University of Athens are women, with 68% being men; only 7% of representatives at the Academy of Athens ( http://www.academyofathens.gr/en) are women.29,30 This stands in contrast to the achievements and performance of women during their time as medical students. Data from the Aristotle University of Thessaloniki for academic year 2016 indicated that female medical students had achieved higher grades on entering the medical school and at graduation. Specifically, regarding final ranking at graduation, 11.7% of female medical students were in the top 10% of the class compared with 8% of male medical students.28 According to data from the Hellenic Association of Orthopaedic Surgery and Traumatology, there are only 30 female orthopedic surgeons vs 1700 male orthopedic surgeons in Greece.

Why orthopedic residency programs generally do not appeal to women is a complex issue. Recognized obstacles have included minimal exposure of medical students to orthopedic surgery, resistance to women entering the field of orthopedics, bias and the outdated belief that orthopedics is physically demanding and requires a lot of strength, poor work–life balance, and a lack of mentors or role models.2,4,31 Studies have suggested that females often prefer female mentors and seek to identify female role models.32,33

Having a role model of the same sex or ethnicity has been reported to be a positive factor for 59% of women compared with 25% of men.34 Nearly 19 of 20 potential mentors in orthopedics are men, and young women may find that mentorship comes from more senior men.33 It has been reported that the #MeToo movement, which has empowered women and exposed the degree of sexual abuse and harassment that persists in the workplace, has made it more difficult for professional women to find men to support their careers.35 Further, this may be used as an excuse to deny mentorship to women in orthopedic surgery.36

The gender composition of a specialty also represents a statistically significant factor in the career decisions of women.37 Sexism impacts women in medicine and female leaders. One study found that women applying to residency programs in orthopedic surgery were asked more illegal questions than men.38 These questions involved marital status (24% female vs 7% male), family planning (61% female vs 8% male), gender (45% female vs 14% male), and children (33% female vs 4% male). It has been reported that, on average, women in academic medicine earn at least 10% less than their male counterparts.39 Furthermore, women remain under-represented in professional societies, on editorial boards, and in positions of leadership.3,4,25,40,41 However, a recent study by Rynecki et al42 found that women were represented equally to or in greater numbers than men as editors and authors for the Journal of the American Academy of Orthopaedic Surgeons, Journal of Bone & Joint Surgery, and Clinical Orthopaedics and Related Research.

Although progress has been made, more changes are needed to eliminate inequities. Disparities must be identified and eliminated in the recruitment of medical students, in the training of residents, and in the employment and advancement of orthopedic surgeons. Women must be promoted to leadership positions within orthopedic surgery, and the development of female orthopedic surgeon role models must be encouraged. These women will serve as mentors for recruiting and retaining more women and can create programs to increase early exposure to orthopedics in medical schools.43 Early exposure to female role models is also important for shaping students' perceptions of the specialty.33,44

Rohde et al43 recently reported that the relatively small number of women currently practicing orthopedics were attracted to the field due to its nature, despite the lack of role models and exposure.43 Furthermore, these authors found that the perception of women who pursue orthopedic surgery as doing so at the expense of a satisfying lifestyle is inaccurate.

The Diversity Advisory Board of the AAOS has commenced a campaign to debunk the myths and misperceptions related to a career in orthopedic surgery with the hope of inspiring medical students to enter the field.45 Also, mentoring programs are available through the AAOS, the J. Robert Gladden Society, and the Ruth Jackson Orthopaedic Society,45 which offer research grants, awards, and traveling fellowships for members. The goal of orthopedic training should not be to make a female into a replica of a male surgeon, but rather to bring a different approach and style.17 Further, it is important for both the specialty and the patients treated that the ideas of women not be excluded.36

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Authors

The authors are from the First Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, “ATTIKON” University General Hospital, Athens, Greece.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Olga D. Savvidou, MD, First Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, “ATTIKON” University General Hospital, 1 Rimini St, 124 62 Chaidari, Greece ( olgasavvidou@gmail.com).

Received: July 20, 2019
Accepted: September 04, 2019
Posted Online: November 06, 2019

10.3928/01477447-20191031-04

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