The Institute of Medicine considers accessibility and diversity a top priority for all individuals pursuing a career in medicine.1 Equal accessibility and gender representation in all medical disciplines has been emphasized in the past several decades, resulting in a dramatic increase of female enrollment in medical schools. In 1970, females comprised only 9% of medical school graduates, compared with 48% in 2014–2015.2,3 Although the total number of female physicians has increased markedly, there are subspecialties of medicine, such as orthopedic surgery, where a significant gender imbalance still exists. According to the 2014 AAOS Orthopedic Practice in the U.S. Report, women account for 5% of orthopedic surgeons currently in practice.4 Gender disparity causes in orthopedic surgery are multifaceted; however, a lack of mentoring relationships available for females interested in orthopedic surgery may play a significant role.5,6
Mentorship, whether formal or informal, is important for both personal and career development. Mentors serve as role models for trainees in a field and can provide support, encouragement, and access to professional opportunities.7 Previous studies have indicated that mentors play a pivotal role in residents and fellows' selection of subspecialties.6,8 Flint et al9 found residents in formal mentoring programs were more satisfied compared with residents with an informal mentor or no mentor.
The role of mentors in the selection of orthopedic surgery as a specialty is unknown. Furthermore, the gender disparity unique to orthopedic surgery may be attributed to a lack of available mentoring experiences for female medical students wanting to pursue orthopedics as a career. Because females compose half of medical school graduates in the United States and only 14% of all orthopedic residents, orthopedic surgery is failing to attract females into the profession.10 The current study sought to (1) determine the prevalence of mentoring relationships in orthopedic surgery, (2) assess the influence of mentors in specialty and subspecialty selection, and (3) evaluate the importance of gender in orthopedic mentoring relationships.
Materials and Methods
An electronic survey was administered to senior orthopedic faculty, fellows, and residents from 3 academic residency programs. Study data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted by Brigham and Women's Hospital health care research computing, Enterprise Research Infrastructure & Services (ERIS) group. REDCap is a secure, web-based application designed to support data capture for research studies.11
Data collection was conducted in September and October 2015. An e-mail with a link to the study survey was sent to a total of 358 attending physicians, residents, and fellows at their respective programs. This study received exempt status from the institutional review board.
Participants were asked to report demographic information such as gender, age, race, subspecialty, and career stage. Orthopedic subspecialty was divided into nine categories, including general, sports/shoulder, hand, joint reconstruction, trauma, foot and ankle, pediatrics, spine, and oncology. Career stage was categorized as pre-practice stage (residents and fellows), early stage (0–5 years in practice), middle stage (6–15 years in practice), and advanced stage (16+ years in practice).
The primary outcome of interest was the prevalence of mentoring relationships among orthopedic surgeons. To determine the presence of a mentoring relationship, participants were asked if they currently have a mentor, had a mentor in the past, or never had a mentor. It was assumed that a mentor was an orthopedic surgeon. Respondents who affirmed that they had a mentor either currently or in the past were asked if their mentor was assigned or self-selected. The secondary outcome of interest was the influence of mentors on choosing orthopedic surgery as a specialty. Participants were asked at what stage in their medical career they had a mentor and in each stage, whether they felt having a mentor positively influenced their choice to pursue specialty or subspecialty.
Career satisfaction and support for career advancement among those who indicated they currently had a mentor was assessed using a modified 16-item career support scale, which contains 5 subscales.12 This measure was scored on a 7-point Likert scale (1=strongly disagree and 7=strongly agree) with a binary classification of items 1, 2, 3, and 4 (disagree or undecided) vs items 5, 6, and 7 (agree).
The availability of female mentors was determined by asking the gender of senior faculty members in the orthopedic surgery department who were available as mentors in medical school, residency, fellowship, or practice. Secondarily, respondents were asked to report the gender of their mentor. All participants were asked whether they preferred a male or female mentor, and whether they thought having the same gender as their mentor was important. In addition, all respondents were asked if they believed their gender was a limitation to professional development. Finally, respondents who reported they never had a mentor were asked whether they wanted to have a mentor at any given time and whether they thought the lack of a mentor was a barrier to their professional development.
A descriptive analysis was performed to assess demographic information and outcomes of interest. Means and standard deviations were presented for continuous variables such as age. Frequencies and percentages were presented for categorical variables such as career stage. The primary outcome of the prevalence of mentoring relationships was calculated as the percentage of respondents reporting having ever had a mentor. The association between outcomes and gender of the respondent was evaluated using bivariate frequencies; formal statistical testing could not be conducted due to the small sample size. All analyses were conducted using SAS version 9.4 software (SAS Institute, Cary, North Carolina).
The study survey was distributed to 358 attending physicians, fellows, and residents. The number of complete responses received was 117 for a response rate of 32.6%; these responses comprised the final analytic cohort. Of the 117 respondents, 95 were male (81.2%) with a mean age of 41.6 (±13.8) years and 22 were female (18.8%) with a mean age of 34.23 (±6.77) years. A total of 100 (85.5%) respondents indicated their race as white, and 17 (14.5%) respondents reported their race as nonwhite. Overall, 41% (n=48) of respondents were still in residency or fellowship training, 15.4% (n=18) were 0 to 5 years into practice, 23.9% (n=28) were 6 to 15 years into practice, and 19.7% (n=23) were more than 15 years into practice. General orthopedic surgery and sports were the most common subspecialties, with 31.6% (n=36) and 19.3% (n=22) of respondents, respectively (Table 1).
Demographic Characteristics of Respondents (N=117)
Prevalence and Influence of Mentoring
Of the 117 respondents, 66.7% (61 males and 17 females; n=78) indicated they had a mentor either currently or in the past, and 93.5% (n=73) indicated they self-selected their mentor. Respondents were most likely to have a mentor during residency (76.9%) compared with medical school (50%), fellowship (44.9%), or practice (33.3%). However, 84.2% (n=32) of respondents indicated their mentor in medical school was influential in their decision to go into orthopedic surgery, and 73.3% (n=44) of respondents affirmed having a mentor in residency was influential in their subspecialty choice. Slightly more than two-thirds (68.6%, n=24) of respondents reported their mentor in fellowship training was influential in obtaining a job or job selection. Of those who had a mentor at some point in their career (n=78), the majority (71.8%, n=56) reported their mentor played a significant role in their career choice. Overall, 66.7% (n=52) were satisfied with their mentoring experience.
Forty-six respondents who reported they currently had mentors responded positively to the 16-item support for career advancement scale. Respondents with mentors reported the most satisfaction with the coaching subscale and the emotional support subscale, whereas the networking subscale yielded the least satisfaction.
For respondents who never had a mentor (n=39), 71.8% (n=28) indicated they did want a mentor at some point. Furthermore, 71.8% (n=28) of participants indicated male mentors were available to them, whereas only 30.8% (n=12) indicated female mentors were available to them. Approximately one-third (38.5%, n=15) of respondents believed the lack of a mentor was a barrier to their professional development.
The Influence of Gender
Although there was a small sample size of females who indicated they currently have or had a mentor in the past (n=17), 14 female respondents indicated the gender of their mentor was male, and only 3 (17.6%) females reported a gender-concordant mentoring relationship. Of the male respondents who currently have or had a mentor in the past (n=61), 96.7% indicated a gender-concordant mentoring relationship.
The majority of respondents (79.4%; n=62) had no preference regarding the gender of their mentor, and 89.3% (n=55) indicated the gender of their mentor did not significantly influence their specialty choice. Furthermore, 73.2% (n=41) of respondents indicated it was not at all or only slightly important to have a mentor of the same gender of the mentee. Only 3.2% (n=3) of males believed gender was a barrier to their professional development, whereas 59.1% of females (n=13) believed gender was a barrier to their professional development.
The majority of respondents (75.6%; n=59) indicated female faculty members in the orthopedic surgery department were present in their residency program. Slightly more than half (51.3%; n=40) of respondents indicated female faculty members in the orthopedic surgery department were present in medical school.
The first and second aims of the current study were to determine the prevalence of mentoring relationships among orthopedic surgeons and the influence of mentors on specialty or subspecialty selection. The third aim was to examine the impact of gender on mentoring relationships and to identify any perceived professional development barriers due to gender.
Prevalence and Influence of Mentoring Relationships
These results indicate two-thirds of respondents affirmed that they currently have or had a mentor in the past. These results were higher than a previous study in general surgery that found 52% of surgical trainees had a mentoring experience.13 In the current study, the majority (71.8%) of respondents who reported a mentoring relationship indicated that having a mentor influenced their specialty choice. Prior studies in academic medicine and general surgery have established that mentoring relationships do influence career or specialty choice.12,14,15 One systematic review reported mentors were influential in a physician's decision to pursue academic medicine.16
In addition to specialty selection, previous literature has indicated that a mentor in residency or fellowship can be influential in determining subspecialty selection.8,9 In the current study, residency was the most common time point when a mentoring experience was reported, and most respondents believed having a mentor in residency was influential in determining their orthopedic subspecialty. The nature of residency training, where residents are paired with senior attending physicians in practice, often is designed as a mentee–mentor relationship and thus may account for the increased prevalence of mentoring experiences during this time.
There is a lack of literature that seeks to determine the influence of mentoring on medical student specialty selection. In the current study, only half of respondents indicated they had a mentor in medical school, yet more than 80% indicated a mentor influenced their choice to pursue an orthopedic residency program. This is contrary to the findings of a study by Wright et al,17 who reported 90% of graduating medical students from one medical school had identified a mentor during their education. Medical students, particularly first- or second-year students, may not have access to senior faculty members or practicing surgeons in specialties of their interest, unless students independently seek out mentoring relationships. The authors surmise the initial years of medical school are perhaps an overlooked or challenging time to establish mentoring relationships, yet this is a stage in medical training when mentors are clearly influential regarding the choice of specialty. Thus, a focus in establishing mentorship for medical students early in their education is essential for directing more students toward specialties such as orthopedic surgery.
The influence of mentors in orthopedics is further solidified by the attitudes of respondents who did not have a mentor. Regardless of gender, these results indicated many respondents who never reported a mentoring experience admitted that they desired one. A previous study among female faculty in an academic medicine setting found 72% wished that they had a mentor at some point.18 However, of those who wanted a mentor, only half believed a lack of a mentor was a barrier to their professional development.
The Influence of Gender
The third aim of the current study was to determine the influence of gender on mentoring experiences within orthopedic surgery. In this study, 77.3% of female orthopedic surgeons indicated they currently have or had a mentor in the past, compared with previous estimates of 54% of academic female surgeons.12 Given the sharp gender disparity, females who are interested in orthopedic surgery may face unique challenges when pursuing the specialty. Several survey studies have found female surgical residents and faculty in academic institutions believe female role models have a significant impact on their careers.15,19–26 One such challenge for females interested in orthopedics may be diminished accessibility to female role models who are established surgeons, potentially due to the low number of female surgeons in practice.4,19,20 A recent study indicated 69% of female orthopedic surgeons thought interested females might not pursue orthopedics as a career choice due to a lack of mentorship in medical school.27 Studies outside of orthopedics have noted discouragement with a lack of female surgical mentors available and have suggested that females may perceive this as a barrier to preferred surgical specialties.25,28
Previous literature examining this issue has highlighted the importance of a supportive network for female surgeons, including mentorship from senior female surgeons, for career advancement.12 Despite a small sample size of female respondents in the current study, more than half perceived their gender to be a limitation to professional development, compared with only 3.2% of male respondents. This finding further highlights the need for future studies to identify causes and consequences of the gender disparity.
Although the majority of respondents in the current study indicated no preference regarding the gender of their mentor, previous studies in general surgery or academic medicine have proposed increasing the number of female mentors as a way to increase female recruitment to certain specialties or practice settings.29,30 The majority of respondents indicated female faculty in the orthopedic surgery department were present during their residency program, yet only half stated female faculty in the orthopedic surgery department were present in medical school. Therefore, accessibility to female mentors or role models in the orthopedic surgery department faculty of medical schools or residency programs should be increased, particularly during critical time points for specialty selection such as medical school.
The majority (95%) of surgeons in the current study self-selected their mentor, indicating that structured mentor programs may be underused or not prevalent in orthopedic surgery. Regarding gender, one study noted female residents had more difficulty in strategizing and initiating contact when self-selecting a mentor.31 Several articles have highlighted the positive influence of structured programs that aim to increase accessibility to role models for females. Mason et al32 found that initiatives, such as a summer internship, positively influenced female students to apply for an orthopedic residency program. The Perry Initiative, which conducts outreach programs to expose and provide mentoring opportunities to first-and second-year medical students, has been successful in increasing the number of females matching to orthopedic residency programs.33
In addition, Bernstein et al34 reported that exposure to musculoskeletal education in medical school increased the likelihood of female medical students applying to orthopedic residency programs. A separate study called for an increase in mentors for female medical students to allow them to gain exposure to successful women in orthopedic surgery.27 Efforts to increase structured opportunities that create mentoring relationships regardless of gender should continue, as respondents in the current study had no preference regarding the gender of their mentor.
Limitations of this study include a small sample size of orthopedic surgeons in a limited geographic area. Although the overall response rate was 32.6%, it is similar to the response rate of a survey study performed in academic medicine.18 There were limited responses from females in the current study. However, the gender distribution in this cohort is representative of both training and practicing orthopedic surgeons.
This study demonstrates that many orthopedic surgeons have mentors at some point in their career. Mentors played a significant role in career and subspecialty choice, yet mentoring relationships were not as prevalent in medical school. The majority of respondents had no preference on the gender of their mentor. This study indicates that mentoring provides a positive influence for both males and females interested in pursuing a career in orthopedic surgery. Increasing and improving access to mentoring experiences, regardless of gender, may play a role in efforts to diversify the gender distribution in the field of orthopedic surgery.
- Smedley BD, Stith Butler A, Bristow LR, eds. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Work-force. Washington, DC: National Academies Press; 2004.
- Association of American Medical Colleges. Total enrollment by U.S. medical school and sex, 2014–2015. https://www.aamc.org/system/files/reports/1/factstableb1-2.pdf. Accessed September 5, 2018.
- Association of American Medical Colleges. The changing representation of men and women in academic medicine. https://www.aamc.org/download/75776/data/aibvol5no2.pdf. Accessed September 5, 2018.
- AAOS Department of Research and Scientific Affairs. 2014 orthopedic practice in the United States report. https://www.aaos.org/2014OPUS/?ssopc=1. Accessed September 5, 2018.
- Van Heest AE, Agel J. The uneven distribution of women in orthopedic surgery resident training programs in the United States. J Bone Joint Surg Am. 2012;94(2):e9, 1–8. https://doi.org/10.2106/JBJS.J.01583 PMID: doi:10.2106/JBJS.J.01583 [CrossRef]22258016
- Hariri S, York SC, O'Connor MI, Parsley BS, McCarthy JC. A resident survey study of orthopedic fellowship specialty decision making and views on arthroplasty as a career. J Arthroplasty. 2011;26(6):961–968.e1. https://doi.org/10.1016/j.arth.2010.09.012 doi:10.1016/j.arth.2010.09.012 [CrossRef]
- McKenna AM, Straus SE. Charting a professional course: a review of mentorship in medicine. J Am Coll Radiol. 2011;8(2):109–112. https://doi.org/10.1016/j.jacr.2010.07.005 PMID: doi:10.1016/j.jacr.2010.07.005 [CrossRef]21292186
- Schiller JR, DiGiovanni CW. Foot and ankle fellowship training: a national survey of past, present, and prospective fellows. Foot Ankle Int. 2008;29(1):34–41. https://doi.org/10.3113/FAI.2008.0034 PMID: doi:10.3113/FAI.2008.0034 [CrossRef]18275734
- Flint JH, Jahangir AA, Browner BD, Mehta S. The value of mentorship in orthopedic surgery resident education: the residents' perspective. J Bone Joint Surg Am. 2009;91(4):1017–1022. https://doi.org/10.2106/JBJS.H.00934 PMID: doi:10.2106/JBJS.H.00934 [CrossRef]19339590
- Brotherton SE, Etzel SI. Graduate medical education, 2014–2015. JAMA. 2015;314(22):2436–2454. https://doi.org/10.1001/jama.2015.10473 PMID: doi:10.1001/jama.2015.10473 [CrossRef]26647275
- Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381. https://doi.org/10.1016/j.jbi.2008.08.010 PMID: doi:10.1016/j.jbi.2008.08.010 [CrossRef]
- Kaderli R, Muff B, Stefenelli U, Businger A. Female surgeons' mentoring experiences and success in an academic career in Switzerland. Swiss Med Wkly. 2011;141:w13233. https://doi.org/10.4414/smw.2011.13233 PMID:21769754
- Healy NA, Glynn RW, Malone C, Cantillon P, Kerin MJ. Surgical mentors and role models: prevalence, importance and associated traits. J Surg Educ. 2012;69(5):633–637. https://doi.org/10.1016/j.jsurg.2012.04.015 PMID: doi:10.1016/j.jsurg.2012.04.015 [CrossRef]22910162
- Stamm M, Buddeberg-Fischer B. The impact of mentoring during postgraduate training on doctors' career success. Med Educ. 2011;45(5):488–496. https://doi.org/10.1111/j.1365-2923.2010.03857.x PMID: doi:10.1111/j.1365-2923.2010.03857.x [CrossRef]21486324
- Healy NA, Cantillon P, Malone C, Kerin MJ. Role models and mentors in surgery. Am J Surg. 2012;204(2):256–261. https://doi.org/10.1016/j.amjsurg.2011.09.031 PMID: doi:10.1016/j.amjsurg.2011.09.031 [CrossRef]22621833
- Straus SE, Straus C, Tzanetos KInternational Campaign to Revitalise Academic Medicine. Career choice in academic medicine: systematic review. J Gen Intern Med. 2006;21(12):1222–1229. https://doi.org/10.1111/j.1525-1497.2006.00599.x PMID: doi:10.1111/j.1525-1497.2006.00599.x [CrossRef]17105520
- Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med. 1997;12(1):53–56. https://doi.org/10.1007/s11606-006-0007-1 PMID: doi:10.1007/s11606-006-0007-1 [CrossRef]9034946
- Blood EA, Ullrich NJ, Hirshfeld-Becker DR, et al. Academic women faculty: are they finding the mentoring they need?J Womens Health (Larchmt). 2012;21(11):1201–1208. https://doi.org/10.1089/jwh.2012.3529 PMID: doi:10.1089/jwh.2012.3529 [CrossRef]
- Burgos CM, Josephson A. Gender differences in the learning and teaching of surgery: a literature review. Int J Med Educ. 2014;5:110–124. https://doi.org/10.5116/ijme.5380.ca6b PMID: doi:10.5116/ijme.5380.ca6b [CrossRef]25341220
- Zhuge Y, Kaufman J, Simeone DM, Chen H, Velazquez OC. Is there still a glass ceiling for women in academic surgery?Ann Surg. 2011;253(4):637–643. https://doi.org/10.1097/SLA.0b013e3182111120 PMID: doi:10.1097/SLA.0b013e3182111120 [CrossRef]21475000
- Benzil DL, Abosch A, Germano I, et al. WINS White Paper Committee. The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery. J Neurosurg. 2008;109(3):378–386. https://doi.org/10.3171/JNS/2008/109/9/0378 PMID: doi:10.3171/JNS/2008/109/9/0378 [CrossRef]18759565
- Shortell CK, Cook C. Importance of gender-specific role models in vascular surgery. Vascular. 2008;16(3):123–129. https://doi.org/10.2310/6670.2008.00024 PMID: doi:10.2310/6670.2008.00024 [CrossRef]18674460
- Ferris LE, Mackinnon SE, Mizgala CL, McNeill I. Do Canadian female surgeons feel discriminated against as women?CMAJ. 1996;154(1):21–27. PMID:8542564
- Hill E, Vaughan S. The only girl in the room: how paradigmatic trajectories deter female students from surgical careers. Med Educ. 2013;47(6):547–556. https://doi.org/10.1111/medu.12134 PMID: doi:10.1111/medu.12134 [CrossRef]23662871
- Levinson W, Kaufman K, Clark B, Tolle SW. Mentors and role models for women in academic medicine. West J Med. 1991;154(4):423–426. PMID:1877183
- Ochberg RL, Barton GM, West AN. Women physicians and their mentors. J Am Med Womens Assoc (1972). 1989;44(4):123–126. PMID:2754173
- Rohde RS, Wolf JM, Adams JE. Where are the women in orthopedic surgery?Clin Orthop Relat Res. 2016;474(9):1950–1956. https://doi.org/10.1007/s11999-016-4827-y PMID: doi:10.1007/s11999-016-4827-y [CrossRef]27090259
- Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, Eidelson B, Mann BD. Influences on medical student career choice: gender or generation?Arch Surg. 2006;141(11):1086–1094. https://doi.org/10.1001/archsurg.141.11.1086 PMID: doi:10.1001/archsurg.141.11.1086 [CrossRef]17116801
- Bernstein J. Male practice: gender inequality in orthopedic surgery. Clin Orthop Relat Res. 2013;471(6):1754–1757. https://doi.org/10.1007/s11999-013-2978-7 PMID: doi:10.1007/s11999-013-2978-7 [CrossRef]23595511
- Walker JL, Janssen H, Hubbard D. Gender differences in attrition from orthopedic surgery residency. J Am Med Womens Assoc (1972). 1993;48(6):182–184, 193. PMID:8263275
- McNamara MC, McNeil MA, Chang J. A pilot study exploring gender differences in residents' strategies for establishing mentoring relationships. Med Educ Online. 2008;13(1):7. https://doi.org/10.3402/meo.v13i.4476 PMID: doi:10.3402/meo.v13i.4476 [CrossRef]20165537
- Mason BS, Ross W, Ortega G, Chambers MC, Parks ML. Can a strategic pipeline initiative increase the number of women and underrepresented minorities in orthopedic surgery?Clin Orthop Relat Res. 2016;474(9):1979–1985. https://doi.org/10.1007/s11999-016-4846-8 PMID: doi:10.1007/s11999-016-4846-8 [CrossRef]27113596
- Lattanza LL, Meszaros-Dearolf L, O'Connor MI, et al. The Perry Initiative's Medical Student Outreach Program recruits women into orthopedic residency. Clin Orthop Relat Res. 2016;474(9):1962–1966. https://doi.org/10.1007/s11999-016-4908-y PMID: doi:10.1007/s11999-016-4908-y [CrossRef]27245771
- Bernstein J, Dicaprio MR, Mehta S. The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopedic surgery residency programs. J Bone Joint Surg Am. 2004;86(10):2335–2338. https://doi.org/10.2106/00004623-200410000-00031 PMID: doi:10.2106/00004623-200410000-00031 [CrossRef]15466748
Demographic Characteristics of Respondents (N=117)
| Male||95 (81.2%)|
| Female||22 (18.8%)|
|Age, mean (SD), y||40.21 (13.06)|
| White||100 (85.5%)|
| Nonwhite||17 (14.5%)|
|Practice stage, No.|
| Resident or fellow||48 (41%)|
| 0–5 years in practice||18 (15.4%)|
| 6–15 years in practice||28 (23.9%)|
| 16+ years in practice||23 (19.7%)|
| General||36 (31.6%)|
| Sports, shoulder, and elbow||22 (19.3%)|
| Hand||19 (16.7%)|
| Joint reconstruction||10 (8.8%)|
| Trauma||11 (9.6%)|
| Foot and ankle||4 (3.5%)|
| Pediatrics||7 (6.1%)|
| Spine||3 (2.6%)|
| Oncology||2 (1.8%)|