Both gender and racial/ethnic diversity in the workplace are conducive to a corporation's success regarding financial performance.1–3 Most executives agree that diversity encourages different perspectives and ideas that foster innovation.4 Even computational studies have shown that heterogeneous groups outperform homogeneous groups in problem-solving.5 The “Rooney Rule” was adopted in the National Football League in 2003, requiring teams to interview at least one minority candidate when choosing a new head coach; it has since succeeded in increasing the number of minority coaches in the league.6 In the realm of education, Harvard President Neil Rudenstine compellingly avowed the value of different perspectives in the pursuit of knowledge—whether the source of diversity is gender, racial, economic, religious, or geographic.7
Minority groups comprise more than 30% of the US population and are projected to become a majority by 2044 (Figure 1).8 “Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population,” as defined by the Association of American Medical Colleges.9 The early Association of American Medical Colleges definition of underrepresented minority (URM) includes blacks, Mexican Americans, Native Americans (American Indians, Alaska Natives, and Native Hawaiians), and mainland Puerto Rican.9 Health policy experts, medical educators, and clinicians recognize the need to diversify the health care workforce to reduce health disparities.10 A medical anthropology study has shown that individuals of different racial and ethnic backgrounds vary considerably in their perceptions and interpretations of symptoms, beliefs about appropriate treatments, reactions to pain and suffering, and understanding of the healer and patient relationship.11
Distribution of the population by race and Hispanic origin for the total population and the population younger than 18 years: 2014 and 2060. The percentages for the total population or the population younger than 18 years may not add to 100.0 due to rounding. Unless otherwise specified, race categories represent race alone. Minority refers to everyone other than the non-Hispanic white alone population. Abbreviations: AIAN, American Indian and Alaska Native; NHPI, Native Hawaiian and other Pacific Islander. (Reprinted from Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060. Washington, DC: US Census Bureau; 2015.)
Unfortunately, disparities in the medical field begin early in the education process and persist despite analyses that account for a broad range of potential confounders.12 A 2014 JAMA study of 90,000 US physicians found that women were significantly less likely to achieve the academic rank of full professor at US medical schools, even after correcting for age, years since residency, specialty, and measures of research productivity.13 Racial and gender disparities are especially notable in academic surgery, where underrepresentation persists at all levels—from residents to junior faculty to professors.14,15
This disparity is greatest in orthopedic surgery. Blacks or African Americans and Hispanics or Latinos comprise 5% of orthopedic faculty, which is lower than that of general surgery (8%) and other surgical and nonsurgical fields.16 Female faculty in orthopedics, at only 12%, also lags behind that in other specialties.17 This disparity persists down the pipeline, as orthopedics has the lowest proportion of minority residents among specialties studied.18 When examining sex, orthopedic surgery also has the lowest proportion of female residents (14.9%).19 When including all practicing orthopedic surgeons (beyond academics), the Orthopaedic Practice in the United States Survey revealed that the proportions of women (6.5%), African Americans (1.5%), and Hispanics or Latinos (1.7%) were even lower.20 Notably, the proportions of African Americans and Hispanics or Latinos have not increased since 2008, being 1.6% and 1.9%, respectively, whereas the proportion of women did increase from 4.0% in 2008.20
As the prominent orthopedic surgeon Augustus White appropriately asserted, the characterization of orthopedics as a predominantly white male ethnocentric profession is not necessarily bad; however, increasing diversity enriches not only patients but also the profession and the nation.21 Diversity has been shown to enhance the educational experience, improve cultural sensitivity, promote professionalism, and increase the number of physicians who will provide care to the underserved.22–24 The current authors posed two questions: What are the barriers to diversity in orthopedics? How can these barriers be broken?
Barriers to Diversity in Orthopedics
One of the issues is the lack of diversity among orthopedic applicants. The proportion of African American and Hispanic or Latino applicants in orthopedic surgery is nearly half of the proportion of African American and Hispanic or Latino applicants in general surgery.18 Likewise, the ratio of female to male applicants to orthopedic surgery is approximately one-third that of female to male applicants to general surgery.18 Possible reasons for this include a lack of family, peer, or community support and disparate levels of academic preparation for this competitive specialty.25–28 Moreover, the financial burden of completing audition rotations, submitting a large number of applications, and traveling to interviews may discourage certain applicants from pursuing orthopedic surgery.27,29,30 A 2015 survey suggested that the percentage of applicants who matched at an institution where they completed a visiting rotation was highest for orthopedic surgery, and that nearly 99% of applicants participated in at least one visiting rotation.31 However, there are surgical subspecialties such as otolaryngology—which is comparably competitive in factors such as US Medical Licensing Examination step scores, Alpha Omega Alpha membership,32 and percentage completing audition rotations31—with greater racial and gender diversity.18,33 Regarding the gender disparity, lifestyle considerations have historically been named a deterrent for women pursuing surgical specialties.34,35 However, these considerations currently no longer seem to significantly differ between the sexes, with male and female surgical residents, fellows, and attending surgeons identifying nearly identical training needs and priorities.36 Together, these data suggest that additional factors unique to orthopedics serve as barriers for women and URMs.
One notable assumption about orthopedic surgery that may discourage female applicants is the existence of a pervasive “old boys club” or “jock and fraternity” culture that values brawn over brain.34,37,38 It is true that orthopedic surgeons employ considerable muscle force, likely greater than that of most other surgical specialties, for certain procedures.39 However, current techniques and technology have decreased the brute strength previously required in orthopedics.37 In fact, evidence suggests that there is no difference between male and female orthopedic residents' performance in technical skills or competency areas set forth by the Accreditation Council for Graduate Medical Education.40
Unfortunately, unconscious bias remains in medicine. A study of recommendation letters for medical school faculty found that letters for women were shorter and more likely to have “doubt raisers” such as negative language or faint praise. An analysis of these letters from a variety of medical specialties found that the language tended to characterize women as “teachers and students” and men as “researchers and professionals.”41 An editorial including personal interviews conducted by Miller and LaPorte37 supported the notion that women are often held to a higher standard than men in orthopedic surgery, with each woman viewed as a representative of her entire sex, especially if there are only one or two women in a program.
A 1998 study42 found no bias against female applicants in the initial chart-review phase of the selection process of 14 orthopedic residency programs. These authors performed a matched pair comparison between female candidate charts and the same charts altered into “male” versions, finding no significant difference in rankings. This study did not preclude the possibility of bias being introduced later in the residency selection process, as another study does suggest that women were more likely to receive potentially illegal questions (regarding their sex, marital status, and family planning) during residency interviews.43 Nevertheless, the proportion of women in the entire orthopedic applicant pool is comparable to the proportion of women in the successfully matched class of residents, and women apply to similar numbers of programs as men.18 Taken together, this suggests that orthopedic surgery residency selection committees as a whole are doing an effective job at not being biased for or against female applicants. Therefore, the crux of the disparity is likely “upstream,” as female students are simply not choosing orthopedic surgery.
A reason for the small proportion of women and minorities choosing orthopedic surgery could be the relative lack of female and minority mentors.18,37,44,45 Although orthopedics has the lowest percentage of women faculty and women residents compared with all other specialties,33,46,47 female orthopedic residents were significantly more likely than their male colleagues to indicate that a role model of their same sex or ethnicity was a determinant in selecting orthopedics.48 Of note, a 2016 survey45 of members of the Ruth Jackson Orthopaedic Society suggested that most current female orthopedic surgeons chose their careers because of their individual personal affinity (eg, enjoyment of manual tasks, personal satisfaction, and intellectual stimulation) for this field despite the paucity of role models or exposure. Nevertheless, the authors contended that the lack of mentorship or exposure may contribute to the continued scarcity of women selecting orthopedics.45
Methods to Improve Diversity
Challenging the status quo requires a multifaceted approach. The reasons for lack of gender and URM diversity are multifactorial and unique from one another, but strategies to address them may have similarities. Increasing exposure is a principal way to connect mentors to mentees and curtail any negative misconceptions of orthopedics. A recent prospective study implemented a required musculoskeletal rotation into the authors' third-year medical school curriculum, increasing the proportion of female and URM applicants to orthopedics by 81% and 101%, respectively.49 Grassroots efforts to provide even earlier exposure and mentorship at all levels (from high school to faculty) would be desirable. As Dr Ames eloquently stated, we should raise “both the ceiling and the floor” in orthopedic surgery by helping people rise above barriers and providing connections to mentors.50
High School and College
Studies have demonstrated that disparities start in secondary education.51–53 Ethnic differences in early education result in disparities in exposure to future careers, ability to enter training programs, and eventual attainment of faculty positions.52 Pipeline programs have been shown to increase diversity, and there are existing options that enable students to explore orthopedics at the high school, college, and medical school levels. For instance, the Perry Initiative is a nonprofit organization dedicated to recruiting and retaining women in orthopedic surgery.54 Led by female engineers and surgeons, the initiative conducts the Perry Outreach Program, which enables high school students to employ problem-solving skills in hands-on surgical procedures with Sawbones.55 A 5-year evaluation of the Perry Outreach Program showed that 93% of participants were enrolled in science, technology, engineering, and mathematics majors in college, with 56% intending to pursue a medical school education.56 In addition, the Perry Initiative has developed Orthopaedics In Action, a hands-on curriculum for middle and high school students that teaches science and mathematics concepts through the lens of orthopedic surgery in science, technology, engineering, and mathematics classrooms.57
The percentage of minority medical students who plan to practice in under-served areas is 4 times that of other medical students.58 It is important to mentor these students and expose them early on to orthopedics. Day et al18 found that minorities are less likely to apply to orthopedics and that they apply to fewer residency programs compared with white applicants, therefore positing that there may have been a lack of mentoring throughout the application process for minority applicants.
Fortunately, there are programs such as Nth Dimensions, which was created to address and eliminate health care disparities through strategic pipeline initiatives. Its 8-week summer internship program has successfully recruited women and URMs and has demonstrated increased matriculation rates into procedure-based residency programs, including not only orthopedics but also general surgery and anesthesia.59 Of the first-year female and URM students who completed the program, 42% eventually applied to orthopedic surgery residencies; this is significantly greater than the national average of 1% of women and 3% of URMs pursuing orthopedics.51 Unfortunately, this program currently has a wait list every year, with many interested applicants not having the opportunity to participate.51
The Perry Initiative also conducts its Medical Student Outreach Program for first- and second-year female medical students nationwide. The Medical Student Outreach Program is structured as a 3-hour exposure program comprised of a series of lectures and hands-on surgical laboratories led by female orthopedic surgeons and residents. The proportion of program alumnae who matched into orthopedic surgery was 28% in 2016, which is double the percentage of women currently in orthopedic residency programs.54 Notably, this program also offers follow-up career mentoring by attending surgeons, potentially connecting interested students with life-long role models.
Role modeling is important. Students who see faculty who “look like them” in certain subspecialties are more likely to consider those careers for themselves. O'Connor60 contends that the successful recruitment of women into orthopedic surgery may be improved by early exposure and access to role models. However, women do not necessarily require female mentors to encourage them to pursue this field. As Dr LaPorte61 aptly conveyed in a commentary, many male orthopedic surgeons serve as outstanding role models; both male and female role models can help improve the diversity of this field by supporting a welcoming culture and dispelling negative stereotypes.
Therefore, faculty participation in the medical school musculoskeletal curriculum should be encouraged. Orthopedic surgery interest groups can facilitate the connection of interested medical students to mentors. Mentors can offer to help review residency applications, provide mock interview opportunities, and demonstrate the importance of work–life balance. In addition, organizations and institutions can provide scholarships to women and URMs for subinternships or research.
Although the essence of the issue does not appear to be overt bias during residency selection,18,42 it is important to continue to emphasize equity and diversity at this stage. Faculty and resident interviewers may benefit from unconscious bias education. There should be attempts to include diverse faculty as part of the interview process, and illegal questions, which are detrimental to programs that ask them, should be avoided.43,60 However, there is sometimes tension between selecting the perceived “best candidates” from the applicant pool and selecting candidates to achieve greater diversity.62 It is easy to select based on objective criteria (ie, board scores, academic standing). It is more difficult to select based on more subjective measures (ie, teamwork abilities, empathy, leadership skills, work ethic, compassion). Hurdles that minority applicants may have overcome should not be overlooked, as successful orthopedic residents are likely to espouse these intangible traits of persistence, dedication, and determination/grit. Therefore, programs that establish comprehensive, multimodal selection criteria, taking into account all aspects of a candidate's application “package,” can increase diversity and reduce health inequities.62
Throughout graduate medical education, role modeling continues to be important. Inviting women and URM faculty as grand rounds speakers or visiting professors may be conducive to connecting young surgeons with potential role models and mentors. Social events such as a “women's night out” or “diversity night” can foster camaraderie and support within a program. An inclusive and welcoming culture should be promoted within the department, along with zero tolerance policies regarding discrimination and harassment.
Travel and board review scholarships are also available for residents and fellows through organizations such as the J. Robert Gladden Orthopaedic Society, founded in 1998 to advance the cause of URMs in orthopedic surgery. It also focuses on practicing culturally competent medical care, with the ultimate goal of improving quality care and eliminating health care disparities.63 In the spirit of organizations such as this, resident research projects in health care disparities can be sponsored and encouraged.
Minority faculty members serve as important role models and mentors to prospective minority trainees. Faculty-to-faculty mentors are helpful and should be encouraged by the institution. Unfortunately, minority faculty members have been historically less likely to be satisfied with their jobs in academic medicine.64 They are more likely to perceive racial/ethnic harassment and bias52,65,66 and describe additional barriers such as poor retention efforts and lack of mentorship that inhibit their success.52 Furthermore, racial, ethnic, and gender disparities in faculty promotion and pay may still exist.13,67 Therefore, institutions should strive for transparency in the promotions process as well as committee, vice chairperson, and other departmental appointments.
In recognizing the importance of recruiting and retaining women and URM faculty members, Butler et al14 suggested applying the Rooney Rule6 to academic surgery. Specifically, they contended that the “Augusta Rule,” which would require the consideration of at least one woman and/or URM candidate for every academic surgical faculty position, may be effective in closing the diversity gap in this field.
Peek et al68 reported survey results that suggested that the most successful strategy found to influence the diversity of faculty at medical institutions was institutional leadership creating a climate “where diversity is high among priorities, in allocating resources to implement policies and practices regarding diversity.” Indeed, orthopedic residency programs whose leadership prioritizes diversity have produced classes with greater percentages of women and URMs.69–71 Moreover, departments with high proportions of URM faculty had strong recruitment/retention packages and opportunities for career advancement for minorities. These successfully diverse institutions used social networks to identify promising candidates, maintained open lines of communication once new faculty were hired, and ensured role modeling and mentoring of junior faculty.68
Diversity is conducive to both education and patient care. However, orthopedic surgery remains the least diverse specialty. There are many potential factors contributing to this dearth of women and minorities in orthopedics. The crux of the disparity appears to be a pipeline issue, as women and URMs are simply not pursuing orthopedic surgery to the same degree as their white male counterparts. Challenging this disparity will require a multifaceted strategy that includes both (1) increasing exposure at all levels to foster the pipeline and (2) maintaining the URMs and women who currently work in this field. Mentors play crucial roles at all levels, from students to residents to faculty. Negative misconceptions must be dispelled. A culture without biases that will encourage individuals from all backgrounds to consider a career in orthopedics must be supported. Diversity of applicants should be pursued and measured. With diversity as a priority, a workforce can be created and maintained in orthopedic surgery that better reflects the US population to reduce health care disparities, improve the overall health of the population, and enrich the field of orthopedics as a whole.
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