Demographic shift underway, more diversity work to be done

A diverse work force may help address health disparities and inequities in orthopedics.

Historically, women were barred from the practice of surgery, making it a profession dominated by men. Even 42 years after Congress passed Title IX, there is still a large disparity in the number of women in the practice.

Although the number of women in the medical field has steadily increased during the years, a study by Chambers and colleagues in The Journal of Bone and Joint Surgery showed orthopedic surgery had the lowest proportion of female residents at 14% in the 2016 to 2017 academic year. The study also reported orthopedic surgery had the lowest percentage of full-time women faculty of all kinds at American medical schools (17.8%).

Similarly, this disparity in orthopedics has been found among African Americans, Hispanics and other underrepresented minorities. According to Ronald A. Navarro, MD, regional coordinating chief of orthopedic surgery at Kaiser Permanente South Bay Medical Center, recent American Academy of Orthopaedic Surgeons data showed African Americans, Hispanics and Asian Americans represent 1%, 1% and 4% of AAOS fellows, respectively, compared with 6% of women.

“We are all recognizing that ... while we have made some progress over the years, there is still a lot to be done when we look at orthopedics compared to some of the other specialties, even in the field of general surgery,” E. Anthony Rankin, MD, professor emeritus at Howard University College of Medicine and past president of the AAOS, told Orthopedics Today.

Source: Sarah A. Borgia

Create a diverse workforce

Sources who spoke with Orthopedics Today noted that diversity in orthopedics is important on a business level and on a patient level. Publications have shown companies that are diverse have varying viewpoints that lead to more innovation and success, according to Valerae O. Lewis, MD, professor and chair of orthopedic oncology at The University of Texas MD Anderson Cancer Center.

“The more differing opinions you have on a particular discussion or topic, the better decision you will come to,” Kristy L. Weber, MD, professor at University of Pennsylvania and incoming president of the AAOS, said.

A diverse work force also may be “a key to addressing health disparities and inequities” with minority physicians more likely to work with underserved and minority populations, according to Rankin.

Lewis noted patients may receive better medical care when they are appreciated culturally or are being treated by physicians who share part of the same culture or who tend to be more culturally aware.

“We try to teach culturally competent care across the spectrum of physicians,” Rankin said. “All physicians should be culturally competent, but ... I think that it is certainly true that patients can relate often to persons of their same ethnicity or gender in that matter,” he said.

Although Lewis noted that while physicians may feel less comfortable working with patients who are different than them, it is OK to be uncomfortable, she said. However, it is important to keep an open mind and make the effort.

“If you take the time to work with someone who is not like you, you will be better for it,” Lewis, an Orthopedics Today Editorial Board Member, said. “Both you and the patient will be better for it.”

Numbers game

However, because only a finite number of people enter orthopedics each year, creating a diverse environment is a numbers game, Weber said.

“We would like to be more diverse, but there is currently a large denominator of non-diverse individuals in the field,” she said. “We want to encourage as many qualified candidates of all types that we can to apply to residency programs.”

A study by Sobel and colleagues in The Journal of Bone and Joint Surgery showed women were more likely to attend residency programs that had more female faculty members, more female associate professors, more women in leadership positions and a higher prevalence of women’s sports medicine programs.

“Orthopedic residency is hard enough that you do not want to always be the first and only woman,” Lewis said.

Rankin noted the results of that study could be translated to underrepresented minorities in orthopedics, as well.

“We do not have a lot of minority faculty, a lot of minority role models and that when medical [students] do not see that those are possibilities, they tend to not go to those specialties,” Rankin said. “Increasing minority faculty, increasing minority leadership role models will certainly help to increase diversity.”

Increase the diversity quotient

One of the first steps to increasing diversity in a residency program or institution is to commit to wanting to be more diverse, looking at applications more inclusively and inviting more diverse individuals to interview, Weber said.

“Maybe you are not even aware of who the minority candidates or women are when you are simply assessing [United States Medical Licensing Examination] USMLE scores,” she said. “You have to be intentional about the women and minority candidates, assessing the qualified individuals and inviting more of them for interviews than you normally do.”

Myths that can deter individuals from pursuing orthopedic surgery, such as the amount of strength needed to perform surgery, should also be addressed. Rachel S. Rohde, MD, noted surgeons do not need as much strength as is rumored to perform most surgeries because they typically use a combination of finesse, mechanical advantage and power tools to accomplish the tasks.

“In most things in orthopedics, if you do not have enough strength to do it, you are probably doing it wrong,” Rohde, an associate professor for orthopedic surgery at Oakland University William Beaumont School of Medicine, told Orthopedics Today.

Rohde also noted that women and minorities need role models to see that it is possible to achieve all of their goals from becoming a leader in orthopedics or being a full-time orthopedic surgeon with a family.

“You definitely have to make choices to try to develop the life that you want, but I think that there are fears that you cannot do everything that you want to do. I think you can — it just might not come in the order you expected. But, not having a visible mentor who exemplifies that discourages some people from applying or from taking that path,” Rohde said.

Importance of mentors, role models

Orthopedic surgeons interested in guiding women and minorities in the orthopedic profession can become mentors, which Navarro believes is “the best tool to allow many who would otherwise have less knowledge of the world of orthopedic surgery become aware.”

“Many of us from different backgrounds did not have dinner parties with orthopedic surgeons so getting awareness about the basics is essential,” Navarro told Orthopedics Today.

In a webinar hosted by the American Orthopaedic Association and The Journal of Bone and Joint Surgery, Julie B. Samora, MD, noted that research has shown mentorship can positively influence career choice, enhance job satisfaction and advance career successes. Both formal and informal mentorships have been found to be beneficial, according to Samora, and meetings with a mentor and other women in the field can address a range of topics, such as goals, obstacles and interpersonal issues.

“We can host informal gatherings where we can not only enjoy each other’s company outside of the health care environment, but can talk about issues such as work-life balance, when to have children, how to handle harassment and biases, as well as other concerns that might not be easily discussed in a clinical setting,” Samora said in her presentation.

Although mentoring programs may be especially beneficial for the scientific careers of women, they are also critical at the attending level, according to Samora.

“Ethnic minority faculty serve as important role models and mentors to prospective minority trainees, but it has been shown that they themselves are less likely to be satisfied with their jobs in academics and are more likely to experience ethnic harassment and racial and ethnic bias,” she said. “Underrepresented minority faculty specifically describe a lack of mentorship that inhibits their successes.”

Acknowledge your bias

Even when working toward building a more diverse environment, individuals may have biases about the performance and capabilities of certain groups that they may not be aware of, Rohde said.

Weber recommends taking the Implicit Association Test, an online test created to educate the public about hidden biases.

“It is an easy way for people to assess their basic biases in the privacy of their own office or home, whether it has to do with race, gender or political orientation, or weight or multiple other categories,” she said.

Weber, who has taken the test multiple times, noted that by identifying and understanding their biases, individuals can work toward thinking about a situation from another person’s perspective. This includes holding conversations and events that are inclusive of all members of the field regardless of gender or race and not using outdated terms to refer to women, such as sweetie, honey and sugar.

“[We need to understand] that female residents and male residents are equally capable of being successful in the field, so we should be treating them as though they will be equally successful and not unconsciously giving a preference to the male side,” Weber said.

How organizations address diversity

As the number of women and underrepresented minorities continues to lag in orthopedics compared with other medical specialties, the AAOS established a Diversity Advisory Board to try to address the problem. Its focus, according to Rohde, is to “diversify the workforce in orthopedics and also to help identify and educate members about musculoskeletal disparities and what we can do to close those gaps.”

“In the newly adopted AAOS 5-year strategic plan approved in December 2018, we are making a commitment to increase diversity in our Board and volunteer structure,” Weber said.

Weber noted the AAOS has planned webinars, in-person programming at the annual meeting and online opportunities on diversity and inclusion topics.

Various societies also have been formed to support women and minorities directly. Founded in 1983 as a support and networking group for women orthopedic surgeons, the Ruth Jackson Orthopaedic Society has become more academic and vocal over the years, according to Lewis.

“[The Ruth Jackson Orthopaedic Society has] had some great leaders of their association and that has done a lot,” Lewis told Orthopedics Today. “They have their meetings along with the Academy and they are also now doing webinars, they are reaching out to members of the Ruth Jackson Society discussing promotion, tenure, getting into orthopedics, dealing with residency and then, when you are out of residency, for whether you are going into academics or private practice,” she said.

Weber noted the J. Robert Gladden Orthopaedic Society is committed to mentoring African Americans and underrepresented minorities in orthopedics. According to the J. Robert Gladden Society website, the society began with the orthopedic section of the National Medical Association (NMA) in 1967 and, as the number of orthopedic surgeons of color increased, the group eventually met at the AAOS annual meeting as the Howard-Meharry Alumni Luncheon. It was formally incorporated as a chartered affiliate specialty society of the AAOS in 1998 and renamed the J. Robert Gladden Orthopaedic Society in 1999.

“[The J. Robert Gladden Orthopaedic Society] has played a role and tried to increase diversity within the profession, and certainly the numbers have increased,” Rankin said.

Navarro noted, American Association for Latino Orthopaedic Surgeons represents orthopedists of Latino descent, and orthopedists who treat individuals of Latino and Hispanic communities.

Although these groups focus mainly on promoting women and minorities in orthopedics, Rohde noted the groups are not exclusive.

“We have many, very active male members of Ruth Jackson,” she said. “In fact, one of the board members is a man. Everyone is welcome.”

Inspire young students

Pipeline programs have also been established with the aim to identify women and minorities interested in orthopedics earlier. The Perry Initiative, which was founded in 2009, aims to inspire young women to become leaders in orthopedic surgery and engineering through hands-on outreach programs for female students in high school, college and medical school.

“[The Perry Initiative] is nationwide, but in our location alone we have had over 500 young women come through the Perry Outreach Program here. The exposure to engineering and orthopedics at a young age, as well as ongoing mentorship, are keys to people becoming interested in pursuing these less obvious fields,” Rohde said.

The Nth Dimension provides resources, expertise and experience to women and underrepresented minorities in orthopedic surgery through its strategic pipeline initiatives.

“Nth Dimension is a program that takes students in medical school and ... exposes them to orthopedics,” Lewis said.

Through Nth Dimension, students can spend a summer with different orthopedic attendings performing research projects that are presented at the NMA, according to Lewis.

“Not only do [students] get exposure to working with orthopedic surgeons and working in the hospital setting, but they also get experience with presenting at the [NMA],” she said.

Collaborate, not compromise

In conjunction with efforts being made by residencies and institutions to be more inclusive and accepting of women and minorities in orthopedics, Weber noted it is important for women and minorities to work hard and be excellent in medical school, as a resident, as a practicing orthopedic surgeon and as a researcher.

“When people are good, it does not matter whether they are minorities or not,” Weber said. “It is harder for people to say anything negative if you are excellent at what you do.”

According to Navarro, the orthopedic profession should be a collaboration and should not be compromised.

“In order to best change the current mix, we would be better served if the candidates from diverse backgrounds did all the expected things incredibly well and were leaders and innovators,” Navarro said. “In my travels and discussions with women and underrepresented minorities, they want to be those things, strive to be in the lead and not get an unfair leg up. We must continue to speak about these topics in a fair and balanced way,” he said. – by Casey Tingle

• References:
• American Association for Latino Orthopaedic Surgeons. Available at: www.aalos.org/. Accessed Jan. 9, 2019.
• Chambers CC, et al. J Bone Joint Surg Am. 2018;doi:10.2106/JBJS.17.01291.
• Culturally competent care guidebook. Available at: www.aaos.org/ccc/assets/pdfs/guidebook.pdf. Accessed Jan. 17, 2019.
• J. Robert Gladden Orthopaedic Society: About. Available at: www.gladdensociety.org/index.php/about/mission. Accessed Jan. 9, 2019.
• Miller, EK, et al. Orthopedics. 2015;doi:10.3928/01477447-20150902-03.
• Our story — Nth Dimensions. Available at: www.nthdimensions.org/our-story/. Accessed Jan. 9, 2019.
• The Perry Initiative: Mission & history. Available at: https://perryinitiative.org/about/mission-statement/. Accessed Jan. 9, 2019.
• Project implicit: About us. Available at: www.projectimplicit.net/about.html. Accessed Jan. 8, 2019.
• Ruth Jackson Orthopaedic Society: About. Available at: www.rjos.org/index.php/about. Accessed Jan. 9, 2019.
• Samora J. Presented at: American Orthopaedic Association/Journal of Bone and Joint Surgery Joint Webinar: Achieving Diversity in Orthopaedics: Taking Action to Drive Change. Nov. 14, 2018.
• Sobel AD, et al. J Bone Joint Surg Am. 2018;doi:10.2106/JBJS.17.01202.
• Torres N. Research: Having a black doctor led black men to receive more-effective care. Available at: https://hbr.org/2018/08/research-having-a-black-doctor-led-black-men-to-receive-more-effective-care. Accessed Jan. 17, 2019.

• For more information:
• Valerae O. Lewis, MD, can be reached at 1515 Holcombe Blvd. #853, Houston, TX 77030; email: kburton@mdanderson.org.
• Ronald A. Navarro, MD, can be reached at 25825 Vermont Ave., Harbor City, CA 90710; email: ronald.a.navarro@kp.org.
• E. Anthony Rankin, MD, can be reached at 7731 Rocton Ct., Chevy Chase, MD 20815; email: erankinmd@aol.com.
• Rachel S. Rohde, MD, can be reached at 26025 Lahser Rd., Second Fl., Southfield, MI 48033; email: rohders@gmail.com.
• Kristy L. Weber, MD, can be reached at 3400 Civic Center Blvd., Philadelphia, PA 19104; email: kristy.weber@uphs.upenn.edu.

Disclosures: Weber reports she is a member of the AAOS Board of Directors. Lewis, Navarro, Rankin and Rohde report no relevant financial disclosures.

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