Although a male-dominated field, more women are pursuing an orthopedic career

The history of orthopedics in the United States has been highlighted by the work of women. In 1937, Ruth Jackson, MD, became the first female board-certified orthopedic surgeon in the country. She wrote The Cervical Syndrome, which for years was a standard orthopedic text. The research of Jacquelin Perry, MD, DSc (Hon), revolutionized gait analysis, and her 1992 book Gait Analysis: Normal and Pathological Function remains a highly regarded text.

Despite these role models, historically few women have entered the field of orthopedics. Other specialties have becoming increasingly diverse, while orthopedic surgery has seen a minimal increase in its female membership.

According to 2011 data from the Association of American Medical Colleges (AAMC), nearly half of all medical students in the United States are women and a fraction of these choose a career in orthopedics. According to 2012 census data from the American Academy of Orthopaedic Surgeons (AAOS), women make up 4.8% of practicing orthopedists in the United States.

In recent years, however, there has been an increase in the number of women selecting orthopedic residencies — increasing from 8.8% in 2001 to 13.6% in 2011. Despite this growth, orthopedics lags behind nearly all other medical specialties. For instance, in general surgery, women comprised 37.1% of residents in 2011. For urology, there were 23.9% women in 2011. Neurosurgery also boasted more female residents in 2011 (15.4%), according to AAMC data.

“If you want this profession to lead the way, to be thought leaders, to discover new technologies, to make progress in the field, you want the best and the brightest,” Jo A. Hannafin, MD, PhD, professor of orthopedic surgery at Weill Cornell Medical College and director of orthopedic research at Hospital for Special Surgery (HSS) in New York City, told Orthopedics Today. “If in medical school 50% of the best and the brightest are female, then you want to attract them to the specialty.”

Ensuring diversity among orthopedic care providers is important for improving the quality of orthopedic research.

“When you diversify, you are going to get different perspectives and different ways of looking at challenges,” Judith F. Baumhauer, MD, MPH, professor and associate chair of academic affairs in orthopedics at the University of Rochester Medical Center, told Orthopedics Today. “It is through those multitudes of different viewpoints that you advance to significant degrees.”

There are multifactorial reasons why women do not pursue orthopedic careers. In this issue, Orthopedics Today talked to some of the leading female orthopedic surgeons in the United States to find out those reasons and the efforts being made to better diversify the specialty.

Our sources noted that women historically avoided the specialty because of a common myth: An orthopedic surgeon had to be physically strong in order to perform rigorous procedures such as total hip arthroplasty; women were deemed incapable of performing such tasks.

“It was considered a physical field,” said Kristy L. Weber, MD, professor of orthopedic surgery at the University of Pennsylvania. “There was a lot of hammering, chiseling and heavy lifting.”

Refinements in surgical technique and equipment have dispelled that myth, opening the field to a variety of people.

“You have to be fit to be an orthopedic surgeon, but you do not have to be massively strong,” Hannafin said.

Exposure in medical school

Another major barrier for women has been a lack of exposure to musculoskeletal topics in medical school.

“[Medical schools] undervalue musculoskeletal care, and [medical students] do not get as much exposure,” Baumhauer said. “There may be no requirements for any rotations in any musculoskeletal care aspect. They may only be able to do it as an elective.”

“In all of medical school, I had 2 weeks of orthopedics in the first 2 years,” Frances Cuomo, MD, chief of the shoulder service at Beth Israel Medical Center in New York and a recent past president of the American Shoulder and Elbow Surgeons and the first female president of this society, told Orthopedics Today. “I got the same as the men; there was no difference in that.”

Required musculoskeletal instruction is becoming more common, according to research by Bernstein and colleagues. In 2003, musculoskeletal courses were required in 65 of 122 U.S. medical schools. In their 2011 progress report, Bernstein and colleagues found 100 of 127 U.S. medical schools now have required preclinical courses in musculoskeletal medicine. Twenty-one schools had no required musculoskeletal instruction, despite that practicing primary care physicians and non-orthopedic specialists commonly see musculoskeletal issues.

An early education in musculoskeletal medicine may have a direct effect on application rates to orthopedic residency programs. According to another study by Bernstein and colleagues, application rates were 12% higher among students who received mandatory instruction in orthopedics. The difference was more striking among women, who had a 75% difference in application rates, and minorities (a 35% difference), suggesting that required musculoskeletal instruction in medical school may promote diversity.

There are different ways medical schools can raise the profile of musculoskeletal medicine. One way is to include musculoskeletal related questions on the United States Medical License Exam.

“That is how you implement change,” Baumhauer said. “You heighten its priority in your testing.”

At HSS, Thomas J. Sculco, MD, chief of the orthopedic department, presents each first-year medical student with an orthopedic textbook, Hannafin said.

In addition, HSS hosts a 12-week summer medical student research program, she said. The 20 to 30 students accepted into the program are paired with an orthopedic surgeon. The program includes lectures on orthopedic topics and operating room time.  

“It gives them exposure to orthopedic surgery in the operating room, and it gives them exposure to an orthopedic research project, which could be basic, translational or clinical research,” Hannafin said. “The hope is to snag the best and the brightest, whether they be male or female, and start them thinking about this as a potential specialty while they are still doing their basic science.”

 

Outreach to high schools

Some organizations are trying to increase exposure by reaching out to high school students. The Perry Initiative, founded by Lisa L. Lattanza, MD, an orthopedic surgeon, and Jenni Buckley, PhD, mechanical engineer in 2009, was designed to teach high school girls about orthopedic surgery and engineering.

“We saw a need for bringing more women into both of those fields that are under-represented,” Lattanza, chief of hand and upper extremity surgery at the University of California, San Francisco, told Orthopedics Today.

The 2009 pilot program included 18 girls who attended underprivileged high schools in the Bay area, according to Lattanza, president of the Perry Initiative.

Today, the Perry Initiative holds more than 25 outreach programs across the country, introducing more than 900 high school and medical students to orthopedics and engineering.

The day-long program consists of three lectures from prominent, local, female orthopedic surgeons and engineers. During the hands-on workshops, the students use real tools and bone models to learn to suture, repair fractures with intramedullary rods and plates, and reconstruct ligaments. The students also conduct biomechanical engineering experiments.

The early results of the Perry Initiative are positive. “We follow [participants] longitudinally, and what we see is that our participants are entering science, technology, engineering and math at five times the rate of the national average,” Lattanza said. “We do not have long enough follow-up at this point to see if the high school students are selecting orthopedic surgery because the program has only been in existence since 2009. We do know that we have made an impact at least into steering them into science, technology, engineering and medicine.”

About 53% of Perry Initiative participants are pursuing premedical degrees; 24% are entering engineering programs, Lattanza said.

Recently, the Perry Initiative has expanded their program to medical students. “What we are trying to do is capture female medical students early in the pipeline, knowing that they may never be exposed to orthopedics in medical school,” Lattanza said.

The Friday evening program includes a lecture from a prominent, female orthopedic surgeon. Next up is an in-depth discussion on femur fractures followed by a hands-on lab where they try out the various treatment methods discussed.

“In our first year of our medical student outreach program, we saw that 90% of the undecided students who we exposed to orthopedic surgery were now interested in orthopedics, where they were undecided before they entered the program,” Lattanza said. “Again, these are early numbers, but we are making a positive impact on those girls as well.”

The lack of role models, particularly female orthopedic faculty, is another key reason those interviewed for this story say women have not chosen to become orthopedists. The good news is that the number of female orthopedists ascending to senior levels in U.S. medical schools is slowly increasing. AAMC data from 2009 show that 29 full professors, 76 associate professors and 183 assistant professors were women. By 2012, there were 44 full professors, 88 associate professors and 229 assistant professors.

Having women in high-profile positions can attract female residents. When Dawn LaPorte, MD, became the resident program director at Johns Hopkins University in 2008, there were two women among the program’s 25 orthopedic residents. This year, six of the 25 residents are women, down slightly from the program high of eight of 25 in 2012.

Having supportive mentors, whether they are male or female, is also important. A strong mentor was critical to attracting Hannafin to orthopedics. Her first orthopedic rotation did little to pique her interest.

“It was in a city hospital, and there were these big, tall guys who were looking at X-rays on the ceiling,” Hannafin said. “It was not a particularly interesting rotation. They did not pay much attention to any of us as medical students.”

A month-long sports medicine elective with Martin Levy, MD, was a different experience. “[Levy] shared how amazing his job was and involved me from the first day,” Hannafin said. “At the end of the rotation, he said to me ‘You could be good at this.’ Suddenly, I thought this is the first time in my life that the academic part of me and the athlete could exist in the same person. I did not have to segment my life.” Hannafin is the first female president of the American Orthopaedic Society for Sports Medicine (AOSSM).

The American Academy of Orthopaedic Surgeons (AAOS), the Ruth Jackson Orthopaedic Society (RJOS) and the Perry Initiative all have active mentor programs.

Surgeon lifestyle

Lifestyle issues, especially the fear of not having enough time to have a family, are another barrier. However, many interviewed said work-life balance is achievable in orthopedics.

“I think orthopedic surgeons, aside from trauma surgeons, control their lives quite well,” Hannafin said. “You can define your own life, and it is a satisfying life. I do not know if that message gets out. I still think in surgical specialties, people find surgery and the hours that surgeons keep frightening, when they think of having a career and having kids and being married.”

An orthopedic career gives women options. “I adjusted my professional life so that I could accomplish what I wanted to in my career, but family always came first,” Cuomo said. “Orthopedics affords that for women.”

Unconscious bias

Bias, unconscious bias in particular, can be another obstacle for women. “There is a discouragement among advising faculty and deans,” said Amy L. Ladd, MD, professor and chief of the Robert A. Chase Hand Center at Stanford University Medical Center in Calif.

“We should not have young women continuing to hear that orthopedics is not the right profession for them. [That] it is not the right profession if they want to have a family,” said Mary I. O’Connor, MD, chair of orthopedic surgery at the Mayo Clinic, Jacksonville, Fla. “It is not the right profession if they are petite. It is not the right profession if they are not an ex-athlete. This ‘jock’ mentality is hurting us.”

The female perspective is important in medicine. “We know that having women in all subspecialties changes the way we practice medicine, changes the way we look at things,” Lattanza said.

That perspective has a significant effect on health care consumption — some patients prefer a female physician. It is also critical to the delivery of health care by “making sure that we are offering the appropriate things to our patients, that we are doing the research that is necessary to make sure that interventions will work the same way on women as they do men,” Lattanza said.

Organizations such as the AAOS and RJOS are focused on closing the gender gap. The AAOS’s Diversity Advisory Board has partnered with Nth Dimensions, an educational, non-profit organization whose mission is to address diversity issues in medicine by increasing the pipeline of medical students heading into orthopedics from the female and ethnic minority populations.

Nth Dimensions sponsors a summer internship for under-represented populations in orthopedics. Participants are usually students between their first and second year of medical school.

“I have a student pretty much every summer,” O’Connor said. “They spend 8 weeks with me. We try to have them do a little research project. It is great exposure. A high percentage of those students have gone into orthopedics.”

By expanding their membership and focus to improve musculoskeletal health with particular emphasis on sex and gender, the RJOS is cultivating future surgeons, mentors and leaders. RJOS aims to achieve better female representation in the leadership of the AAOS and across the orthopedic subspecialties.

“[It] is a bottom-up concept of reflecting who we represent and having a voice,” Ladd said. “The more we cultivate our membership, the more we will have a presence at the leadership level as well.”

The goal of the diversity movement is not to achieve a 50/50 split between genders. “I think what we have to do is remove the barriers so that as many women who want to go into orthopedics and have a qualified background can do so,” Weber said. “I do not think we are there yet.”– by Colleen Owens

What is the most effective way to draw women to the field of orthopedic surgery?

Have an open educational environment

The most effective way to attract women to orthopedic surgery is a topic that has been discussed broadly, and it varies according to the group addressing the problem. The next level of effort will take longer term changes to make a difference. They will involve continuing the progress that has been made and building on successful efforts. Many of these longer term changes will occur gradually without much additional effort.

Since at least half of incoming medical students are women, it is possible at some point to have 50% of the orthopedic future work force be women. I prefer not to think of what the ideal ratios should be. The most important thing I believe is that with time, the percentage of women will be one that includes all of the qualified and dedicated women who want to be orthopedic surgeons with a residency position.

Our field should continue to support, mentor and encourage medical students and younger students who express an interest in the specialty. It will take time to increase the number of female orthopedic surgeon role models in the medical school environment and community. This will require more female professors, lecturers and treating clinicians. While the percentage of female residents is currently small, the number of women in tenured faculty positions is even smaller.

Medical students, regardless of gender, have various and individual reasons for deciding to not pursue orthopedic surgery. There will always be specialties that appeal to one gender more than the other. Despite many individual variations that direct students into their chosen fields, it remains important that we encourage medical students to gain exposure to the specialty during orthopedic fellowships and rotations.

I believe the most important thing we can do as a profession is to remain committed to eliminating unintended barriers to women who want to be orthopedic surgeons. We have come a long way in this area, but still have further to go. One survey of residencies done more than 20 years ago revealed 52 existing residencies had never accepted a woman. This has and will continue to change. Female orthopedic resident candidates know which residency programs have accepted women, what the experience of those previous residents has been and whether these residents are encouraging others to follow in their footsteps.

We need an educational environment for medical schools that portrays the challenges and opportunities in orthopedic surgery with role models to which male and female students can relate. Our goal needs to include attracting the best candidates. Since half of those potential candidates are women, we need a continued building process to encourage, mentor and attract the best-qualified future orthopedic surgeons.

Douglas W. Jackson, MD, resides in Long Beach, Calif.
Disclosure: Jackson is the former Chief Medical Editor of Orthopedics Today.

Early exposure is critical

This is a call to action to increase the number of women in orthopedic surgery. We know that women represent nearly half of all medical students in the United States throughout the past several years. However, at this time, 13% of orthopedic residents and 4% of fellows in the American Academy of Orthopaedic Surgeons (AAOS) fellows in 2009 were women, according to Van Heest and colleagues.

What can we do to attract women to the field of orthopedic surgery? First, we have to look at early exposure to the field. In an article by Johnson and colleagues about medical students choosing orthopedics as a career, factors that many believed important included faculty contacts and clinical exposure. Most orthopedics-bound resident respondents to the survey were more likely to be strongly influenced by experiences prior to medical school.

Thus, before people enter medical school, it is important that they have access to role models who demonstrate that women can succeed in the field of orthopedic surgery. That is why, I suggest that all female orthopedic surgeons — residents, faculty and private practice doctors — make themselves available to discuss and promote their career choice. Options include high school career days and shadowing experiences.

Once you have one female orthopedic surgeon in a residency or practice, it appears to be easier to attract more female orthopedists. However, there is an uneven distribution of women in orthopedic surgery resident training programs in the United States. This was a topic of an article by Van Heest and Agel. They confirmed that orthopedic residency programs do not train women with equal frequency. From 2004 to 2009, 45 programs had no female residents during at least one of the 5-year review and nine programs had no female residents during any of the years. More than 50 orthopedic programs had an average of 10% female trainees during the 5-year period, and there were 10 programs that had an average of 20% or greater female trainees. This distribution did not change during the time period.

My call to action also involves deans of medical schools, chairs and program directors. It is important to have qualified female faculty and residents. Residents should not be chosen because of gender. I am asking for consideration in the hiring of diverse, qualified faculty and residents. Programs need to look critically at trying to increase diversity to accurately reflect the composition of women in medical school and orthopedic residency so they may begin to influence the number of women fellows in the AAOS. On a national level, it is important that there are female role models and leadership positions within the AAOS and subspecialty societies.

Having positive female role models is the key to attracting more women to the field of orthopedic surgery. I urge all female orthopedic surgeons to positively influence young women in their area from high school and beyond who express an interest in orthopedic surgery. We have a job to do: attracting more of us into orthopedics. It is a job I take seriously.

We know orthopedic surgery always has some of the star medical students. There is no reason to believe that with 48% of U.S. medical students being women, that they are not more star medical students who are qualified to be orthopedic surgeons. They just need to be encouraged by seeing another female orthopedic surgeon. Anyone reading this article who is involved in orthopedics — no matter your title — I encourage you to do your job to improve the numbers of female orthopedic surgeons in the United States.

Lisa K. Cannada, MD, is an associate professor at St. Louis University, St. Louis, and an Orthopedics Today Editorial Board member.
Disclosure: Cannada is a past president of the Ruth Jackson Orthopaedic Society (RJOS) and a current member of the RJOS board of directors.