Is the profession lagging behind in the diversity of trainees?
In terms of diversity in orthopaedic surgery, the primary focus has been on gender. Issues of gender diversity have recently been highlighted by the media, giving rise to social and professional outcries for more women in the field.

But diversity encompasses more than gender and, although essential, the recent push for more women in the field falls short of addressing the limited racial and ethnic diversity of orthopaedic surgeons.

Women account for 14.5 percent of orthopaedic surgery residents, considerably more than Hispanics/Latinos (3.5 percent), African-Americans (5.4 percent), and Asian-Americans (11.8 percent).

Shifting demographics
Diversity, or the lack thereof, is a controversial topic, not only in orthopaedic surgery but throughout all aspects of the medical profession in the United States. Limited multiculturalism within medicine, with respect to sex, race, and ethnicity, is increasingly concerning as the nation's demographics become more diverse. Minorities—including Hispanics/Latinos, African-Americans, and Asian-Americans—currently constitute more than 30 percent of the U.S. population and are expected to increase to more than 50 percent by 2042, resulting in the first "majority by minorities" in the nation's history.

However, the racial/ethnic composition of the U.S. physician workforce does not reflect the changes seen in its general population. Minority groups represent only 6 percent of U.S. physicians. Orthopaedic surgeons are overwhelmingly Caucasian males, and orthopaedic surgery remains one of the least diverse specialties in medicine. Promoting diversity among orthopaedic trainees and decreasing ethnic healthcare disparities are essential concerns with significant implications for patients, their healthcare providers, and the orthopaedic profession.

Health disparities across racial and ethnic groups in the United States are well documented. African-Americans and Native Americans trail Caucasian Americans in almost every healthcare metric, including mortality, hospitalizations, and average life expectancy.

For example, ethnicity has been reported as a major risk factor for inadequate emergency department analgesia. In one study, Hispanics patients with isolated long-bone fractures were twice as likely as non-Hispanic whites to receive no pain medication in their emergency center. Furthermore, African-American and Hispanic patients tend to report lower satisfaction with medical care than their Caucasian counterparts.

Addressing the issue
Diversity among physicians is an important step toward improving patient satisfaction and addressing healthcare inequalities. Compelling evidence supports the need to increase diversity within orthopaedics to ensure high-quality medical education, access to health care for the underserved, advances in research, and improved business performance.

Recent studies have demonstrated that patients who are treated by a healthcare provider with a similar cultural background not only have an improved ability to communicate and convey essential medical information, but are also more likely to be satisfied with the treatment they receive. Higher satisfaction ratings in physicians' participatory decision-making style have also been noted when patients and physicians are race-concordant.

Minority physicians are more likely to provide health care to African-American and Hispanic/Latino patients, to serve poor, uninsured patients, and to locate their practices in underserved areas. This helps alleviate the documented inequalities in the availability of orthopaedic care. Furthermore, minority healthcare providers are more likely to pursue research topics on gender and diversity issues, as well as on health disparities.

Although diversity has improved at the medical school level, and among orthopaedic surgery residencies, the degree of diversity in orthopaedics is considerably less than in the medical profession as a whole. The percentage of African-American and Hispanic/Latino residents in the United States has steadily increased (+ 0.55 percent and + 1.37 percent per decade, respectively). However, both groups account for less than 5 percent of current trainees.

Minority representation among orthopaedic surgery residents is the lowest of all specialties, primarily due to a lack of Hispanic/Latino and Asian-American residents. This lack of representation extends beyond the training years; Hispanics/Latinos, African-Americans, and Asian-Americans are even further underrepresented among orthopaedic faculty.

As minorities become a larger percentage of the total U.S. population, a parallel increase in diversity among orthopaedic trainees is needed to ensure high-quality, culturally competent health care. Previous efforts to promote diversity can help formulate new strategies to increase ethnic diversity in orthopaedic surgery. Evidence supports a correlation between making diversity an institutional goal through professional platforms and increased minority representation.

Providing early, required courses in orthopaedic and musculoskeletal medicine during medical school has been shown to correlate with higher rates of application to orthopaedic surgery residency programs among all students, particularly minority groups. However, few medical schools require an orthopaedic or musculoskeletal rotation, and many students graduate with an inadequate exposure to the field and its faculty.

Active mentoring and access to role models have been described as crucial factors that influence minorities' interest in orthopaedic surgery. One study found that an ethnically diverse program and targeted minority recruitment efforts were important factors for minority applicants considering a residency program. Academic programs that seek to address diversity concerns may consider amplifying their efforts when hiring faculty. Having more minority and female role models will likely affect both the level of interest in orthopaedics among medical students and the nature of the resident-selection process.

A recent study reported that medical students who completed an orthopaedic summer internship program as part of a target pipeline curriculum for underrepresented minorities were more likely to apply to orthopaedic surgery residency. The strategic pipeline developed by Nth Dimensions implemented a longitudinal curriculum consisting of the following three phases:

• clinical correlations and sawbones bio-skills workshops
• orthopaedic summer internship program
• ongoing mentoring and professional development

In developing future strategies to attract more diverse orthopaedic surgery trainees, it is important to understand what attracts applicants to a specific specialty.

The reasons that orthopaedic surgery as a field lags in diversity are multifaceted and complex, but remain unclear. Factors that undoubtedly contribute to the problem include a lack of interest and exposure to the field, concerns about lifestyle, and scarce support from orthopaedic mentors for minority students.

Several important initiatives to increase diversity in orthopaedic surgery have been implemented. The AAOS identifies diversity as one of its nine strategic goals and its Diversity Advisory Board is charged with improving the delivery of culturally competent care and diversifying the profession.

In addition, the J. Robert Gladden Orthopaedic Society (a multicultural advocacy group), the American Association of Latino Orthopaedic Surgeons (a Latino advocacy group) and the Ruth Jackson Orthopaedic Society (an advocacy group for women in orthopaedics) continue to identify and improve underrepresentation of minority groups in the field.

Improving diversity in orthopaedic surgery will take a concerted and resolute effort for years to come. Much work must be done to close the gap in diversity between orthopaedics and other medical specialties. Prioritizing the active recruitment of minorities earlier in their medical education and emphasizing the crucial implications of promoting diversity to patient care and the profession are crucial.  

We would like to acknowledge the Resident Assembly and its members for their contributions to this article.

José H. Jiménez-Almonte, MD, is a member of the Resident Assembly Education and Research Committees, and a resident member of the Trauma Content Committee. Andrew R. Jensen, MD, is vice chair of the Resident Assembly Executive Committee, and is a member of the Resident Assembly Education, Research, Practice Management, Health Policy, and Technology Committees, as well as a resident member of the Shoulder & Elbow Content Committee. Jason H. Ghodasra, MD, is a member of the Resident Assembly Health Policy Committee. Wayne W. Chan, MD, PhD, is an orthopaedic surgeon practicing in Connecticut.

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