Diversity in orthopedic surgery: Underrepresentation starts immediately after medical school

Charles S. Day, MD, MBA, answers 4 Questions about the current approaches needed to achieve more diversity in orthopedic surgery.

Introduction

When I entered orthopedics, it was primarily comprised of a Caucasian male population. One of my intern colleagues told me, somewhat tongue in cheek, that I had chosen a “fat white cats” specialty. Since that time, the fabric of orthopedic surgery has changed to be more diversified. We are still a male-dominated specialty, but changes are occurring.

I have always strongly believed that we should remove all unintended barriers and encourage diversity in our profession. The American Academy of Orthopaedic Surgery (AAOS) has made great strides in this effort since the 1990s, but it takes an ongoing awareness and vigilance. This month, I asked Charles S. Day, MD, MBA, associate professor and director of the orthopedic curriculum at Harvard Medical School, to share his observations and conclusions about his recent study on diversity in orthopedic surgery.

— Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: Orthopedic surgery as a specialty has historically lacked the diversity of the general population and other specialties, as well as the medical school application pool. What does your study reflect on the current diversity in our residency programs?

Discuss in OrthoMind

Charles S. Day, MD, MBA: Diverse physicians lead to higher patient satisfaction, as patients are more comfortable with doctors who share their culture. While orthopedic surgery as a specialty has historically lacked the diversity of the general population and the medical school application pool, past AAOS president Douglas W. Jackson, MD, appointed an ad hoc committee to explore diversity issues in orthopedic surgery in 1997. Since then, there have been numerous published studies spotlighting this issue. However, no study has critically compared the diversity in the field of orthopedic surgery with other surgical and nonsurgical fields.

Charles S. Day

In our recently published study, we quantitatively analyzed the current composition of orthopedic surgery training programs according to race, ethnicity and sex from medical students applying to and entering the field as residents to academic and senior faculty members, comparing orthopedics to general surgery and other fields along each point in the training and promotion trajectory. When the current resident population of orthopedic surgery was compared with that of general surgery, the general surgery resident composition more closely mimicked the diversity of the medical school graduates, but minorities were underrepresented in orthopedic training programs.

Currently, about 19.8% of orthopedic residents identify themselves as Asian American, African American, Hispanic or Latino, while 34.2% and 33.4% of medical school graduates and general surgery residents, respectively, have this identification.

This underrepresentation starts immediately after medical school. African Americans and Latinos are half as likely to apply for orthopedic as opposed to general surgery programs. For every African American applicant to apply to an orthopedic surgery residency program, there were 13.5 white applicants. This lags far behind the ratio for general surgery, which is one African American applicant for every 5.7 white applicants. This trend is also seen in Latinos, where there are 14.1 white applicants for every Latino applying for orthopedic surgery residencies, and six whites for every Latino applying for general surgery residencies. For Asians, the ratios are 6.1 to 1 and 3.6 to 1, respectively.

These results may suggest medical student disinterest or barriers of entry into orthopedics. African Americans and Latinos tend to submit fewer residency applications in general, which may be indicative of the financial difficulties with the high cost of applications and inadequate mentoring by faculty. This disparity in application rates is reflected in the resident pool. African Americans comprise 4% of the orthopedic surgery residents, which is significantly less than their representation in general surgery, pediatrics or internal medicine. Latinos make up 3.8% of orthopedic surgery residents, lower than any other field, and this difference was significant for all fields except otolaryngology. Even among Asian Americans, who are not considered underrepresented minorities in medical school, there was a significantly lower proportion of orthopedic residents, 12%, than in numerous other surgical and nonsurgical fields.

Jackson: How does the diversity in our training programs compare with the diversity seen in academic orthopedic surgery positions?

Day: After entering orthopedic surgery as residents, minorities tend to progress more slowly to higher faculty ranks, but as with residencies, minorities are increasing in representation among orthopedic faculty and full-time professors. African Americans are equally represented in orthopedic surgery, otolaryngology, general surgery and internal medicine at around 2.5%, while they are far better represented in family medicine and pediatrics. Hispanics comprise 2.4% of orthopedics faculty, significantly lower than any other field except otolaryngology. While Asian Americans represent 12% of orthopedic residents, they comprise 9.1% of orthopedic surgery faculty, the lowest representation of Asian American faculty in any field except family medicine.

When faculty representation was compared with full professor representation, there were small, non-significant decreases in both African American and Latinos and a significant decrease for Asians. In general surgery, contrasting with their residency composition, representation of full professors significantly decreased in all minority groups. As with residents, while the orthopedics faculty overall is less diverse than any other field, with faculty identifying themselves at 14% Asian American, African American, or Hispanic/Latino, minority faculty representation has increased in the past decade.

From 1996 to 2006, African Americans and Latinos have increased about 0.6% in faculty representation, perhaps due to more support from the orthopedic community, although they still comprise less than 3% of faculty. The orthopedics community’s recent focus on diversity has improved minority representation, but there remains more need for attention to this issue.

Jackson: There are many reasons orthopedic surgery may not reach the diversity seen in medical schools for women in our specialty. What are some of the reasons that a smaller percentage of the women in the potential applicant pool are applying for training as orthopedic surgeons?

Day: Women are underrepresented in general surgery programs as compared with medical school graduates, and even more so in orthopedic surgery programs. While women comprise 49% of medical school graduates, they represent 12.4% of orthopedic surgery residents, significantly lower than any other field except neurological surgery. Women also comprise only 13.4% of orthopedics faculty, significantly lower than their representation in any other field. This underrepresentation of women in orthopedics stems from the medical school application process – 6.3 men apply for orthopedic residencies for every female applicant, whereas that ratio is 2.2 male general surgery applicants for every female applicant to general surgery.

Unpublished data from a survey of second year Harvard medical students show that fewer women are interested in orthopedic surgery than are interested in general surgery or other surgical specialties. This finding is surprising even though 50% reported that they were intellectually interested in the musculoskeletal system. When female students were asked about factors determining their career choices, they mostly cited “flexible lifestyle” followed by “diversity within the specialty,” perhaps suggesting concerns about family life and work-life balance. And even though they viewed the financial rewards of orthopedic surgeons as favorable (>95%), they were nevertheless deterred by perceptions of low diversity, high competitiveness and lengthy training. Moreover, 81% of female students stated that diversity within orthopedics is “unfavorable” or “very unfavorable.”

However, as the female residents of years past mature into faculty and senior faculty, they can become valuable role models of diversity for young female residents and provide mentorship through the competitive application and training process. As the percentage of female full-time professors increased from 1.5% to 3.8% from 2001 to 2006, the percentage of female residents followed from 9% to 12.4%.

Jackson: What current and additional approaches might be taken by our specialty to achieve more diversity?

Day: Increasing diversity in orthopedic surgery can be employed in two ways: encouraging faculty members to appeal to minority medical students and increasing all medical students’ exposure to orthopedic surgery. Progress has been made, as African American and Latino representation in faculty has increased by about 30% in the last decade and female representation by about 30% in the past 5 years. Just as female faculty seem to be encouraging increasing numbers of female orthopedic residents, current faculty encouraging Asians, African Americans and Latinos to enter orthopedic surgery residency programs will likely continue to improve minority representation.

The other area to focus on in improving orthopedic diversity is exposing more medical students to mandatory orthopedic courses. This exposure in medical schools increases both the competitiveness of minorities and women in applying to residencies and their interest in the orthopedics field. A two-pronged appeal to students and faculty will help the orthopedics field become more diverse and lead ultimately to improved quality of care for all patients.

Reference:

• Day CS, Lage DE, Ahn CS. Diversity based on race, ethnicity, and sex between academic orthopedic surgery and other specialties: A comparative study. J Bone Joint Surg (Am). 2010;92:2328-2335.

• Charles S. Day, MD, MBA, can be reached at Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215; email: cday1@bidmc.harvard.edu.