It was with interest that I read "Women in Orthopaedics: The Attraction Is Mutual." I was encouraged by the evidence of progress presented by Drs. Cannada and Teuscher regarding more women becoming interested in training to practice orthopaedics and become leaders in the field. The data referenced by the authors show similar trends to those presented in another recent study by Van Heest et al. Orthopaedics has the second largest cadre of women in training in absolute numbers behind general surgery (105 women and 440 women respectively in the 2014–2015 academic year), even though orthopaedics ranks lowest among the top eight surgical specialties when considering trainees on a percentage basis within all programs (14 percent for orthopaedics in the 2014–2015 academic year).

On the other hand, I was disappointed to see that the list of orthopaedic organizations for which women have served as president did not include the Western Orthopaedic Association (WOA). Although the authors did focus mostly on "specialty organizations," they also included the American Board of Orthopaedic Surgery. It is unfortunate to have missed the opportunity to tout the impressive record we have in the West. Three women have served as president of the WOA in recent years: Linda J. Rasmussen, MD, from Hawaii (2008–2009); Ellen M. Raney, MD, originally practicing in Hawaii and now in Oregon (2012–2013); and Valerae O. Lewis, MD, from Texas (2013–2014). The WOA prides itself on its progressive stance and record on this issue, as well as the fact that it has a diverse board of directors. The WOA strives to be inclusive and welcoming to all orthopaedic surgeons.

Yes, we have more work to do and can always do better, as others have echoed. Nonetheless, we should celebrate the successes that we do achieve along the path. The WOA will continue to push the envelope on this and many other issues of critical importance to our profession.

Robert R. Slater Jr, MD

Authors' response:
Thank you for your kind comments regarding our article, Dr. Slater.

The WOA, with its record of electing deserving women to key leadership roles, is truly a leader among associations. It was an honor for us to present at the 2015 WOA annual meeting on the topic of women in orthopaedics. That presentation served as the impetus for "Women in Orthopaedics: The Attraction Is Mutual."

As you noted, three women have served as president of the WOA in recent years. We know each of them professionally. In addition, one of us was fortunate enough to have served on the WOA board of directors with each of these highly qualified and talented colleagues.

Our AAOS Now piece was limited to reporting on the AAOS and the American Board of Orthopaedic Surgery, as well as the Board of Specialty Societies (BOS). Notably, the BOS is made up of 23 member organizations, more than half of which have been represented by female presidents. While we did not expand our article to include the regional orthopaedic or the state orthopaedic societies, we are pleased to report that female presidents have led or will soon lead nine state orthopaedic societies.
Congratulations on your achievements. It is our hope that many other orthopaedic societies will follow in your footsteps. 
Lisa K. Cannada, MD
David D. Teuscher, MD

References:

1. Cannada LK, Teuscher DD: Women in Orthopaedics: The Attraction is Mutual. AAOS Now August 2016, p.1.
2. Van Heest AE, Fishman F, Agel J: A 5-year update on the uneven distribution of women in orthopaedic surgery residency training programs in the United States. J Bone Joint Surg 2016; 98A:1328.

"Women in Orthopaedics: The Attraction Is Mutual" (AAOS Now, August 2016) by Lisa K. Cannada, MD, and David D. Teuscher, MD, immediate past president of the AAOS, supports a "glass half-full" concept of the strides made in our profession. We agree with the authors that figures can be deceiving; indeed, data misrepresentation can be dangerous and hurt efforts to promote and attain true diversity in orthopaedic surgery. Lack of gender and ethnic diversity in orthopaedics, and medical specialties in general, affects patient access to care and decisions that are made about care, as well as innovation and progress. Studies indicate it is downright harmful. Research has shown that patients prefer to obtain care—and receive better care—from physicians who have a similar background with respect to gender, ethnicity, and race.

Although the percentage of female residents in orthopaedics is increasing, it has risen only 7 percent in nearly 2 decades (19 years). Without significant and sustained efforts, it is mathematically unlikely that women will account for 30 percent of orthopaedic surgeons by the close of the century. (This is the number generally considered to be acceptable to confer diversity in a defined group and allow self-sustaining diversity to continue in that defined group.) Rather than congratulating ourselves on the small amount of progress that has been made, therefore, we should be refocusing and escalating efforts to improve diversity. 

With regard to deceptive figures, percentages DO matter. No matter how you look at the numbers, the specialty of orthopaedic surgery has been unable to move the needle past 14 percent women trainees. Meanwhile, all other surgical subspecialties, including urology and neurosurgery—traditionally male-centric—have left us in the dust in terms of percentages of women.

We appreciate the authors identifying the accomplishments of individual women in our specialty. These represent, however, just a handful of women in leadership roles over a period of many years. For example, the only woman president of the American Society for Surgery of the Hand served a decade and a half ago, despite women in hand surgery accounting for approximately 25 percent of all hand fellows. Most orthopaedic societies, whether or not within the Board of Specialty Societies, have never had a woman president.

We encourage AAOS Now—and all AAOS members—to focus on solutions that foster diversity and inclusiveness within orthopaedic surgery. This includes commitment of energy and support for initiatives by Nth Dimensions, The Perry Initiative, AAOS Diversity Advisory Board, Ruth Jackson Orthopaedic Society, J. Robert Gladden Orthopaedic Society, and the American Association of Latino Orthopaedic Surgeons. In addition, reaching out through the Orthopaedic Surgery Interest Groups and continuing efforts to standardize exposures to orthopaedic surgery/musculoskeletal medicine during medical school will also be critical to enhance and diversify our specialty.

As the authors pointed out, all orthopaedic surgeons, regardless of gender, ethnicity, age, and practice profile, can help by mentoring talented students. A single positive early student experience can go a long way toward stimulating interest in the field of orthopaedic surgery. The authors contradict themselves, however, with respect to the importance of mentoring with regard to choosing orthopaedic surgery. Again, there is ample evidence to support that mentorship and early exposure are very important factors in choosing orthopaedic surgery. We cannot in any way lessen our responsibility and need to seize any and every opportunity to mentor an individual to choose orthopaedics. It is a win-win for all.

Respectfully,
Lisa L. Lattanza, MD
Melvyn A. Harrington Jr, MD
Ramon L. Jimenez, MD

Authors' response:
We appreciate the comments and insights from three champions of orthopaedic workforce diversity regarding our article, "Women in Orthopaedics: The Attraction Is Mutual."

In our article, we endeavored to highlight the progress that has been made regarding orthopaedic diversity and to encourage effective mentorship of future female orthopaedists. No matter which medical/surgical specialty one is recruiting for, it is important that those chosen represent the best, brightest, and most capable medical students who will complete their graduate medical experience and become board-certified physicians as well as leaders in our professional organizations. For this to happen, we must provide support for all residents during their training.

Although we tried to present a balanced report of our collective progress in increasing involvement of women in orthopedics, we acknowledge that our specialty still has a long way to go, as evidenced by a variety of data, including a recently published study by Holt et al that found that females were more likely than males to leave their orthopaedic residency programs. Thus, it is not time to take a victory lap as if we have completed the mission.

And yet, progress is most certainly being made. Since the publication of our article, the 2017 AAOS Nominating Committee has recommended that Kristy L. Weber, MD, be elected as the new second vice-president of the AAOS. We applaud the committee's recommendation of Dr. Weber, who would become the first woman to join the presidential leadership line of our Academy.

We believe all can agree to collegiality as a core value of the AAOS. An important part of that collegiality is a commitment to promoting a culture of inclusiveness that, in turn, will make orthopaedics an attractive specialty to the top of the applicant pool. We must continue to work toward improving diversity in orthopaedic surgery, not just in regard to women but to all underrepresented minorities.
Lisa K. Cannada, MD
David D. Teuscher, MD

Reference:
http://www.clinorthop.org/articles/10.1007/s11999-016-4923-z

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