Orthopedics

Guest Editorial Free

Barriers to Women Entering the Field of Orthopedic Surgery

Emily K. Miller, BA; Dawn M. LaPorte, MD

The movement toward official academic training for medical professionals in the 12th and 13th centuries led to the exclusion of women from professional health care because they were excluded from universities.1–3 Although women were barred from the practice of surgery, they were able to fill roles as bone-setters. The treatment of musculoskeletal conditions was largely the domain of bonesetters in the centuries before the 1850s. After the advent of anesthesia and antibiotics, the profession of orthopedic surgery developed rapidly, and the bonesetters slowly disappeared.

After passage of the 1972 Education Amendments to the Civil Rights Act in the United States, including Title IX4 on sex-based discrimination, the number of female graduates from medical schools began increasing at a steady rate, tripling by 1980.5 However, the percentage of women in surgery lagged behind that in medicine: in 1980, 12% of physicians, but only 2% of surgeons, were women.6 Notably, the percentage of female residents in orthopedic surgery grew at a slower rate than that in other surgical subspecialties (Table 1).6,7

Female Residents by Specialty and Year

Table 1:

Female Residents by Specialty and Year

This editorial takes a historical perspective to investigate the key barriers to attracting women to the field. We distributed a survey that focused on exposure to orthopedic surgery to all members of the Ruth Jackson Orthopaedic Society. Of the 777 members, 267 (34%) female orthopedic surgeons and residents responded (Table 2). This represents approximately 20% of all female orthopedic surgeons. Seven personal oral history interviews were conducted with Drs Liebe Diamond (who completed residency in the 1950s), Michelle James (1980s), Mary O’Connor (1980s), Beth Shubin Stein (1990s), Dawn LaPorte (2000), Casey Humbyrd (2010s), and Julia Smart (2010s).

Womena in Residency Programs by Year of Residency Completion

Table 2:

Women in Residency Programs by Year of Residency Completion

Previous research has shown that women’s performance in orthopedic residency programs equals that of men,8 and that women are accepted into orthopedic surgery residency programs at the same rate as men.9 However, women are more underrepresented in orthopedics than in any other specialty.

Lack of exposure to orthopedic surgery before and during medical school is one of the most commonly cited reasons women do not apply to orthopedic residencies. A 2012 analysis reported on medical students’ motivations to enter specific fields. Only 15% (76 of 495) of students not pursuing orthopedics cited experiences before medical school as the most influential, compared with 27% (34 of 125) of those pursuing orthopedics. However, women pursuing orthopedics had influences similar to those of medical students pursuing other fields, with only 15% (3 of 20) citing previous exposure and 80% (16 of 20) citing experiences during the clinical years of medical school.10 In our survey, 76% of respondents had some exposure to orthopedic surgery before medical school. Although prior exposure to orthopedic surgery is important for generating initial interest, experiences during medical school are even more influential for women who pursue orthopedic surgery.

Unfortunately, musculoskeletal education in medical school has historically been deficient.11 Seventy-five percent of survey respondents reported having less required exposure to orthopedic surgery in medical school compared with other specialties like otolaryngology. Required instruction in musculoskeletal medicine was associated with a 12% higher rate of application to orthopedic surgery residency programs among all students and a 75% higher rate among women.12 In schools with limited or no required musculoskeletal education, prior exposure to orthopedic surgery is essential for students to take the initiative and seek out experiences in orthopedic surgery.

Survey respondents commonly mentioned the following previous exposures to orthopedics: athletics-related patient experiences (31%), non–athletics-related patient experiences (21%), experience in a related occupation (8%), and having a family member or close friend who is an orthopedic surgeon (5%) (Figure 1). The relationship between athletic involvement and orthopedic surgery is multifaceted. Medical students who have participated in athletics are more likely to have previous exposure to orthopedics than are their nonathlete classmates. Additionally, athletes may be more interested in the mechanics of the body and movement and, therefore, may be more likely to be drawn to the field. The historical exclusion of women from sports participation put women at a disadvantage in terms of orthopedic surgery exposure through athletics. Before the enactment of Title IX4, boys’ participation in high school sports was approximately 50%, whereas girls’ participation was only 3.7%. Now, the percentage of girls participating in high school sports has increased to 40%.13 In our survey, 84% of female orthopedic surgeons responded that they had played sports in high school and/or beyond (Figure 2), and 46% stated that athletics influenced their decision to enter orthopedic surgery. This percentage increased with the year that respondents finished residency, with 28% (8 of 28) of those finishing in the 1980s and 55% (68 of 123) of those finishing after 2010 confirming that athletics influenced their decision to apply in orthopedic surgery. B. Shubin Stein, MD, noted in her practice, “I have had lots of young women who have had injuries and surgeries with me who have come back and chatted with me as students who clearly have an interest in going into the field now because of their injury” (oral communication, October 2012).

Survey respondents reported the context in which they first were introduced to the field of orthopedic surgery. Patient experiences, both related to athletic activity and not, were the majority of responses.

Figure 1:

Survey respondents reported the context in which they first were introduced to the field of orthopedic surgery. Patient experiences, both related to athletic activity and not, were the majority of responses.

Survey respondents indicated their self-reported levels of athletic participation. Eighty-four percent of respondents participated in athletics competitively in high school and/or beyond. Percentages do not sum to 100 because of rounding error.

Figure 2:

Survey respondents indicated their self-reported levels of athletic participation. Eighty-four percent of respondents participated in athletics competitively in high school and/or beyond. Percentages do not sum to 100 because of rounding error.

Another major historical barrier to women entering the field of orthopedic surgery is gender bias. Although overt bias plays less of a role now than in the past, unconscious bias continues to be an obstacle.9 C. Humbyrd, MD, explained that women in orthopedics are often held to a higher standard, or hold themselves to a higher standard, because when there are only 1 or 2 women in a program, each woman is seen as a representative for her entire sex: “When a woman doesn’t do well, it’s like the whole sex is taking a hit, whereas when a guy isn’t doing well—well, that guy sucks” (oral communication, July 2012). This phenomenon may diminish as programs increase their percentages of women.

In addition, women were far more likely to cite the importance of a role model of the same sex and/or of similar ethnicity than were their male counterparts.14 This was strongly supported in oral histories. All interviewees were able to pinpoint specific female mentors or role models who influenced their choice of orthopedic surgery as a specialty. An approximate threshold of 30% has been defined as the level of visibility necessary to avoid appearing to be a male-dominated profession.15 Unless women see other women in the specialty, they are less likely to choose it.16–18

Furthermore, there are 3 major assumptions about orthopedic surgery that contribute to discouraging female applicants: (1) the uncontrollable and busy lifestyle intrinsic to the specialty; (2) the necessity of enormous physical strength; and (3) the overwhelming “jock and fraternity” culture9,19,20 (C. Day, MD, unpublished survey, Harvard University, 2012). These assumptions are only partially based in fact, but are common in medical education and may discourage women from seeking exposure to orthopedic surgery.

First, the expectation of an unmanageable lifestyle in orthopedics was refuted by interviewees who know many orthopedists with manageable lifestyles (M. James, MD, oral communication, July 2012; B. Shubin Stein, MD, oral communication, October 2012).

Second, orthopedic surgery has greatly progressed from the brute force discipline of the past, with new techniques and equipment decreasing the strength requirement. B. Shubin Stein, MD, assures women that “with the right technique and the right tools, I can do everything the boys can do” (oral communication, October 2012). Unless female medical students work with female attendings, they may never learn that many things done by brute force could also be accomplished by more technical means. In fact, 57% of female medical students in the United Kingdom cited the physical aspects of the specialty as a major deterrent.19

Finally, orthopedic surgeons are often portrayed as the “dumb jocks” of medicine by those in other specialties.20,21 In a recent survey of Harvard medical students, despite female respondents’ interest in the musculoskeletal system, none of them was considering orthopedics as a specialty. Of the students surveyed, 54.4% (43 of 79) suggested minimizing the jock and fraternity culture of orthopedics as the best way to improve the attractiveness of the specialty (C. Day, MD, unpublished survey, Harvard University, 2012). Those with athletic exposure are less likely to avoid orthopedics because of its reputation for having a jock and fraternity culture (M. I. O’Connor, MD, oral communication, July 2012).

In conclusion, women are more underrepresented in orthopedics than in any other specialty. Athletics is the most common way in which young women are initially exposed to the field, and the majority of female orthopedic surgeons (84%) reported having played competitive sports. Survey respondents reported less exposure to orthopedics in medical school than to other specialties, which may be an important barrier to the recruitment of women. Lack of sufficient female role models in the field also impairs recruitment. One possible way to overcome the previously cited barriers and combat the misconceptions about orthopedic surgery is to provide medical students with opportunities to identify people in the field to whom they can better relate while simultaneously providing practitioners the opportunity to contradict misperceptions about orthopedic surgery.

References

  1. Benton JF. Trotula, women’s problems, and the professionalization of medicine in the Middle Ages. Bull Hist Med. 1985; 59(1):30–53.
  2. The Royal College of Surgeons of England. A brief history of women in surgery. http://www.rcseng.ac.uk/museums/archives/documents. Accessed September 26, 2014.
  3. Pastena JA. Women in surgery: an ancient tradition. Arch Surg. 1993; 128(6):622–626. doi:10.1001/archsurg.1993.01420180020004 [CrossRef]
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  5. Boulis AK, Jacobs JA. The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America. Ithaca, NY: ILR Press; 2008.
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  7. Center for Workforce Studies. 2012 physician specialty data book. https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf. Accessed September 26, 2014.
  8. Pico K, Gioe TJ, Vanheest A, Tatman PJ. Do men outperform women during orthopaedic residency training?Clin Orthop Relat Res. 2010; 468(7):1804–1808. doi:10.1007/s11999-010-1318-4 [CrossRef]
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  11. Schiötz EH, Cyriax J. Manipulation Past and Present: With an Extensive Bibliography. London, United Kingdom: Heinemann Medical Books; 1975.
  12. Bernstein J, DiCaprio MR, Mehta S. The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopaedic surgery residency programs. J Bone Joint Surg Am. 2004; 86(10):2335–2338.
  13. Stevenson B. Title IX and the evolution of high school sports. http://whartonsportsbiz.org/documents/research/TitleIXandtheEvolutionof-HighSchooSports-11-07.pdf. Accessed September 26, 2014.
  14. Hill JF, Yule A, Zurakowski D, Day CS. Residents’ perceptions of sex diversity in orthopaedic surgery. J Bone Joint Surg Am. 2013; 95(19):e1441. doi:10.2106/JBJS.L.00666 [CrossRef]
  15. Kanter RM. Men and Women of the Corporation. New York, NY: Basic Books; 1977.
  16. Carnes M, VandenBosche G, Agatisa PK, et al. Using women’s health research to develop women leaders in academic health sciences: the National Centers of Excellence in Women’s Health. J Womens Health Gend Based Med. 2001; 10(1):39–47. doi:10.1089/152460901750067106 [CrossRef]
  17. Yedidia MJ, Bickel J. Why aren’t there more women leaders in academic medicine? The views of clinical department chairs. Acad Med. 2001; 76(5):453–465. doi:10.1097/00001888-200105000-00017 [CrossRef]
  18. Porucznik MA. Where are the women orthopaedists?AAOS Now. http://www6.aaos.org/news/PDFopen/PDFopen.cfm?page_url=http://www.aaos.org/news/aaosnow/feb08/cover2.asp. Accessed September 26, 2014.
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Female Residents by Specialty and Year

Specialty Year
1970a 2001a 2010b
Orthopedic surgery 0.61% 8.97% 13.2%
Neurosurgery 0.90% 10.59% 13.9%
Urology 0.27% 12.69% 23.1%
Otolaryngology 0.64% 18.55% 32.3%
General surgery 2.36% 23.74% 36.2%
Ophthalmology 3.69% 32.41% 41.4%
Obstetrics and gynecology 4.79% 71.41% 81.4%

Womena in Residency Programs by Year of Residency Completion

Year of Residency Completion Women in Program, No.
Unanswered/Unclear, No. Total, No.
0%–4% 5%–9% 10%–14% 15%–19% ≥20%
1970–1979 1 (25%) 1 (25%) 1 (25%) 0 (0%) 1 (25%) 0 (0%) 4 (1.5%)
1980–1989 2 (7%) 8 (28%) 8 (28%) 3 (11%) 7 (25%) 0 (0%) 28 (10.5%)
1990–1999 3 (7%) 11 (26%) 11 (26%) 7 (16%) 8 (19%) 3 (7%) 43 (16.1%)
2000–2009 10 (16%) 19 (30%) 13 (21%) 5 (8%) 13 (21%) 2 (3%) 62 (23.2%)
2010–2016 5 (4%) 18 (14%) 22 (17%) 32 (25%) 45 (35%) 8 (6%) 130 (48.7%)
Authors

The authors are from the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Dawn M. LaPorte, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Fl 5, Baltimore, MD 21205 (editorialservices@jhmi.edu).

10.3928/01477447-20150902-03

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