In 2007, women accounted for 49 percent of all applicants—and 48 percent of all enrollees—in medical schools, according to the Association of American Medical Colleges. Within specialty societies, women make up about 35 percent of residents, according to a survey of the 17 organizations in the Specialty Society CEO Coalition.

In orthopaedic surgery, however, the story is much different, reported Mark C. Gebhardt, MD, chief of orthopaedic surgery at Beth Israel Deaconess Medical Center, to the combined Board of Councilors/Board of Specialty Societies (BOC/BOS) meeting last fall. Less than 10 percent of orthopaedic surgical residents are women—the lowest percentage among all residency programs.

“About 10 percent to 12 percent of applicants to orthopaedic residency programs are women,” said Dr. Gebhardt, “so we are selecting in proportion to the applications. There just aren’t enough women applicants!”

Why does such a disparity exist? Why are so few women attracted to orthopaedics—and what does that mean for the future of the specialty? In this and future issues of AAOS Now, we will examine this issue and the steps being taken to attract more women to the field.

The candidate pool
“There’s so much we don’t know,” Elizabeth A. Ouellette, MD, president of the Ruth Jackson Orthopaedic Society (RJOS), told the BOC/BOS. “How many women apply to orthopaedics? How many are accepted? How many complete their residency? How many pass their board certification? How many remain in practice as surgeons or in other physician careers? How many leave—and why?”

Finding the answers to these questions will take time—and time is rapidly running out. If orthopaedic surgery continues to attract just men, the pool of candidates will be smaller—while workforce projections are indicating a growing need for more orthopaedic surgeons.

“We will lose more than half of our applicant pool unless we find a way to attract more women to our training programs,” said Dr. Gebhardt. “If we want to continue to attract the top 10 percent of the medical school class, we need to make orthopaedic surgery more acceptable to women.”

Numbers aren’t the only reason orthopaedics needs to attract more women. “Women bring a different perspective to the specialty,” noted Dr. Gebhardt. “Exposure to individuals who have different life experiences, are a different gender, or are from different cultures changes a student’s prior assumptions. White male students learn to interact better with female and minority patients, which increases the quality of care and the satisfaction of both patient and physician.”

“Women are socialized to seek connection,” say the authors of “Gender Issues,” a chapter in the new Guide for Women in Orthopaedic Surgery, recently released by RJOS (see review on page 57). “Men are socialized to seek hierarchy. We [women] communicate; they [men] jostle for status.”

Dr. Gebhardt also pointed out that women are often better organized and able to “get things done” better than their male counterparts. They may be more likely to be involved in their communities and may listen and interact with patients differently.

Why don’t women apply?
Several reasons have been posited for the lower rates of application to orthopaedic residency by women and minorities, including minimal exposure to musculoskeletal topics during medical school, lack of mentoring or role modeling, and differential recruitment by current orthopaedic faculty and residents. In academic orthopaedics, bias and outdated beliefs create barriers that hamper women’s advancement.

The importance of exposing students to musculoskeletal topics as a way of encouraging their participation in orthopaedics can be seen—and heard—in the stories of current female orthopaedists. For example, during her orthopaedic residency, Valerae O. Lewis, MD, currently interim chief of the department of orthopaedic oncology at the University of Texas’ MD Anderson Cancer Care Center, enjoyed the “team-like atmosphere” that prevailed among the orthopaedic residents.

Kimberly Templeton, MD, associate professor of orthopaedic surgery at the University of Kansas Medical Center, was first introduced to orthopaedics through a series of personal sports injuries. She was attracted to the “hands-on aspect of orthopaedic surgery,” which complemented her own interest in “arts and crafts and putting things together and fixing them.”

Lisa K. Cannada, MD, assistant professor at the University of Texas Southwestern Medical Clinic, thinks that orthopaedics may need to reach students even before they enter medical school and has some suggestions for involving community orthopaedists in the recruiting effort.

“I think the time to start is early in the first year, or even before their entrance into medical school,” said Dr. Cannada. “Many high schools sponsor career days. The opportunity to speak with a female orthopaedic surgeon could have a profound effect on students as they make career choices. Some schools have shadowing programs. Or contacting the local television station to discuss issues pertaining to women can provide a ‘face’ and a contact point for students and the community.”

“Medical schools need to promote women and minorities for all residency programs,” Dr. Gebhardt told the BOC/BOS, “and expose medical students to fields such as orthopaedics in their formative years.”

Such a step would not only generate interest in orthopaedics, it would also give students the opportunity to meet surgeons and develop mentoring relationships, another important way to increase the number of female applicants to orthopaedic residencies.

The need for more female faculty
Mentors and faculty role models are significant factors in attracting women to orthopaedics. “When female medical students don’t see many women in the field, they may be discouraged,” said Dr. Templeton.

“Having more female faculty role models is important,” agrees Dr. Gebhardt. Unfortunately, many programs are still dominated by male faculty. At the Harvard residency program, there are just seven female faculty. According to the RJOS, only 12 percent of orthopaedic faculty are women, and only 7 percent of all orthopaedic physician faculty members are women. Just 15 women hold full professorships in orthopaedics. There is one female orthopaedic chair.

Mentoring programs—such as those provided by RJOS, the J. Robert Gladden Orthopaedic Society, and the AAOS Diversity Advisory Board—can be helpful in expanding the number of role models.

Dispelling the myths
Although still seen as an “old boys’ network” that requires a resident to be strong and burly, orthopaedic surgery is changing. Advances in arthroscopic and surgical instruments, as well as the advent of new technologies, have reduced the need for brute strength in the operating room.

Bias still presents a barrier to academic appointments, reported Mary I. O’Connor, MD, chair of the AAOS Women’s Health Issues Advisory Board and chair of orthopaedic surgery at the Mayo Clinic in Jacksonville, Fla. For example, a recent report by the National Academy of Science points out that high-school girls are now performing as well as boys in mathematics and that the publication productivity of women faculty in science and engineering is now comparable to their male counterparts.

In one area, however, women are unique. “So many people believe that because women take more time off due to childbearing, they are a ‘bad investment,’” said Dr. O’Connor. “And, on average, women do take more time off during their early careers to meet their care-giving responsibilities. But over an entire career, a man is likely to take significantly more sick leave than a woman.”

Residency programs
Some residency programs—such as those at Johns Hopkins, Harvard, and the University of Minnesota (UM)—are taking active steps to recruit more women. “It requires the commitment of the chairman and/or the program director, as well as a focus on more than grades or qualifying test scores during the admission process,” said Dr. Gebhardt.

Elizabeth A. Arendt, MD, professor of orthopaedic surgery at the UM program, pointed to the following three factors in achieving that program’s above-average number of women participants: a department chair (Roby C. Thompson Jr., MD) who advocated for women, women in visible positions who serve as role models and interact with medical students and residents, and a pervasive sense of fairness in resident and faculty issues and oversight.

In addition, the Accreditation Council for Graduate Medical Education (ACGME) and the orthopaedic Residency Review Committee (RRC), under the direction of Richard E. Grant, MD, has discussed ways to increase diversity in residency programs. The RRC recently approved the following steps to increase the number of women and underrepresented minorities in orthopaedics:

• Working with appointing organizations to increase the diversity of the RRC
• Increasing the diversity of the Special Site Visitor roster, the individuals who review the program
• Changing the program requirement language so that residency programs must explain their plans to diversify their program and resident complement during site visits
• Changing the program information file and site visitor report form to include questions on plans for increasing diversity and gender
• Adding a program requirement to make cultural competency an integral part of the curriculum
• Encouraging the ACGME to share data regarding ethnicity with the RRC
• Adding gender and diversity language to fellowship forms and requirements

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Resources:
Ruth Jackson Orthopaedic Society: www.rjos.org
J. Robert Gladden Orthopaedic Society: www.gladdensociety.org
AAOS Diversity Advisory Board: www.aaos.org/diversity
For additional resources and links to other articles on women in orthopaedics, visit www.aaosnow.org