Five women in orthopaedic surgery assess the environment in their profession and offer their hope for improvement
Over the past year, the issue of sexual harassment has risen in the public conscience in an unprecedented way. The #MeToo movement took shape and gained forceful momentum as men in prominent positions in government, entertainment, and corporate industry were called upon to account for incidents of inappropriate behavior toward women that previously went unreported, unheeded, and unpunished.

If a sea change has occurred in how sexual harassment and discrimination against women is discussed in the public arena, few would argue that sexism has been eradicated. Women continue to face barriers and threats to safety.

In medicine, as in other professions that long were male-dominated, progress toward fair and equal treatment of women has been real, if slow in coming, but is certainly not complete.

Women, who now make up half of new physicians, still face situations, in training and then in practice, in which they are made to feel like second-class citizens and are met with harassment and bullying, whether in overt incidents or in still-common subtle ways.

In orthopaedics, women surgeons remain a decided minority. The sheer numerical disparity, along with lingering vestiges of institutional and cultural sexism, present ongoing challenges for women in orthopaedic surgery.

To address these challenges and issues, Jennifer M. Weiss, MD, moderated a roundtable discussion with four colleagues—Elizabeth G. Matzkin, MD; Alexandra Page, MD; Coleen S. Sabatini, MD; and Kristy L. Weber, MD—who related their experiences as women and leaders in orthopaedic surgery.

The discussion
After initial exchanges among the participants, Dr. Weiss summarized the consensus that emerged: “The group is unanimous that harassment—specifically, harassment of women—and bullying exist in the world of orthopaedics.”

In the 90-minute roundtable session that followed, the group agreed that harassment and bullying detract from engagement and contribute to burnout—defined as disengagement or withdrawing or feeling unable to provide good patient care or to contribute to the profession well and fully. Dr. Matzkin observed that “depending on how one may react to bullying or harassment, I think you can use that energy and turn it into positivity or it can certainly contribute to burnout in a different way.” That different way can be characterized as resilience, a word, observed Dr. Weiss, “that is near and dear to the hearts of women in orthopaedics.”

Dr. Page expressed astonishment that “the self-reported rate of burnout among orthopaedic surgeons is about 35 percent higher for women than men.” “Shouldn’t the professional factors that lead to burnout be agnostic to sex or gender?” she asked, while noting from her own published work that there are three domains in burnout, one of which is low sense of personal accomplishment. “When we talk about the more subtle ways in which harassment can happen, that would include being told that you’re not strong enough,” she said, as when a woman in the training stage fails to reduce a joint or fracture and the care is transferred to a man, or when a male trainee is more assertive or aggressive, and is “given the knife” or made primary surgeon instead of a similarly skilled woman in the same stage of training.

Dr. Weber honed in on the notion of resilience. She noted that in an environment made more toxic by harassment or bullying, the responsibility of maintaining one’s own wellness is increasingly challenging.

Dr. Sabatini raised the oft-confirmed observation that women “are multitaskers,” often by necessity. “We tend to take on a lot of responsibilities in our workplaces,” she said. “These roles expand beyond those of orthopaedic surgeon and include providing emotional support and care for our colleagues, staff, and patients’ families in addition to their own families,” she said. “Often women try not to express any vulnerability or display anything that might be perceived as weakness. Many women that I know really work to an extreme and don’t want to say no if asked to take something on; they don’t want to complain or bring to the attention of others that perhaps there are too many things on their plate. So, women tend to work excessively, in order to avoid being seen as anything other than an equal contributor.”

When asked to recall words that they have said to a bully or harasser, the participants expressed shared memories of missed opportunities. Even as the respected leaders and mentors they are today, they said they are sometimes too hard on themselves.

One participant recalled standing up on a regular basis to a chief in a past work location. She said she let him know—not always in public—that “he was denigrating” and said that she tried “to help him see the better side of the people he was hurting with his words and behavior.”

Dr. Sabatini noted, “We are no longer in an era where this behavior is acceptable. Just knowing and having somebody say to you that you don’t deserve to be made to feel that way or, you don’t deserve to be spoken to that way serves as an important step forward in empowering those who may have been subject to previous bullying or harassment.” She said she is thankful that “we’re moving into an era where certain behaviors are no longer going to be tolerated.” Her favored tactic when she hears something negative is to ask the speaker to repeat their words, hoping that they will respond to the implied invitation to self-correct. Dr. Page pointed out that sometimes direct confrontation is necessary and recalls relaying the message to a male junior resident: “This is not about your ego. Back off. It is about patient care and it is about doing what is right to your colleague.”

Intolerance not tolerated
Dr. Weiss noted that she met recently with Anthony Johnson, MD, a retired military surgeon now at UT Health Austin’s Musculoskeletal Institute, when he sought her out to offer support for women in orthopaedics. In their conversation, Dr. Johnson cited words from the military: “Not on my watch.” Dr. Weiss asked the group about the potential benefit of a campaign with the hashtag of those words, “in which we engage the 94 percent of orthopaedic surgeons who are men in our conversation of doing what is right and declaring zero tolerance for harassment and bullying.”

“I think, #notonmywatch is fantastic,” Dr. Sabatini said. “It reminds us that we’re all responsible for making sure that our workplaces are an environment where everybody can thrive and nobody is belittled or made to feel, ‘less than.’ This is not just for women, but also for people of color and others who face discrimination in medicine. This is for our patients who might be from a different background or speak a different language. Whatever it is, nobody is ‘less than.’ We are all responsible for making sure that people are supported and can thrive.”

Dr. Matzkin commented: “The most important thing is that we just need to continue to empower each other with positivity and continue to remind ourselves that we all have sisters and mothers and brothers and fathers, and we need to equally respect and treat everyone how they deserve to be treated.”

Dr. Weber acknowledged the challenge of “getting people to stop and think about whether they would make that comment to their mother or perform that action on their daughter. I think the point is to get the guys to see the situation from the other person’s perspective. We have to thread the needle between standing on a soapbox and risking them disengaging from the conversation versus providing feedback in a way that becomes a nonthreatening teaching (‘aha’) moment.” She is realistic and seeks to ensure that women communicate “with our male colleagues in a way that allows them to hear it and see it and think, ‘I can do a better job.’”

Message to mentees
To frame the #MeToo phenomenon in a personal way, Dr. Weiss asked the group, “If you have a daughter, or a niece, or a school-aged mentee or relative, what do you share about staying strong in the face of bullying?”

Dr. Matzkin’s words of advice to young women included the recommendation to stay positive, confident, assertive but not aggressive, and to remain clear in communication. Dr. Sabatini offered the fundamental reminder that people do not deserve to be treated poorly. When a situation arises that demands a response, she recommended “confronting that situation in a productive way—that takes a conversation tailored to the situation and who is doing the bullying.” Dr. Weber advised colleagues to find role models “with the values and behaviors they admire” and to observe and emulate them. Dr. Page expressed her view that motherhood taught her to stand up for herself, and to be a “better champion for others who are bullied.”

During the discussion, the participants were asked to relay an incident in which bullying or harassing behavior impacted patient care in an unexpected way. This led to a conversation about inappropriate interactions with patients and the issue of boundaries for female physicians. Dr. Page recalled an incident with a patient. As a friendly, warm person, giving a hug to patients was not uncommon for her, but she remembered the time “a hug turned into an attempted embrace from a patient.” She explained, “That experience made me unnaturally stiff with my male patients for probably a decade until I figured out the right way to do it. That’s a completely different twist, but women physicians need to be prepared for setting boundaries with patients as well as colleagues.”

Dr. Weber observed, “The patient who is bullying either me or my female residents has, ultimately, impacted his or her own care because I have a hard time spending as much time with them or being maybe as generous as I would normally. Patients can negatively affect their own care if they are not appropriate.”

Dr. Sabatini spoke of the difference between male and female physicians in taking on nurturing roles. She posited that “it seems that sometimes there is an expectation that women are going to have a more gentle and patient bedside manner and if they don’t, patients see this as a negative for the women surgeon where they may not for the male.” From conversations with female surgeons around the world, she pondered whether a “definitive” demeanor is more acceptable coming from male than female surgeons. If this is the case, patient expectations can “set up some challenges” in the doctor-patient relationship.

Dr. Matzkin relayed the uncomfortable but not uncommon situation when a patient addresses their female surgeon by names such as “sugar,” “sweetheart,” or “honey.” Respect is difficult to maintain when these words are used to describe a physician.

The group agreed that some areas of orthopaedics have attracted more women than others, such as academic practice and pediatric orthopaedics. Dr. Weber said a positive outgrowth of this circumstance is that “where there are more women, there will be strength in numbers and a culture that’s less amenable to harassment and bullying.” She notes that in the academic world, with its intensely hierarchal structure, bias and unequal treatment may occur increasingly as women “move up the ladder of power and influence.”

Advice to my younger self
Dr. Weiss asked the group, “If you could travel back in time and meet a younger version of yourself after the very first time you were bullied or harassed as an orthopaedic surgeon, what would you tell yourself?”

One surgeon shared that she made a conscious decision to stay off “the soapbox” and to bide her time until she “got to a point where I had more credibility and more authority to affect behavior change and expect different behavior.” She admitted, “I feel bad that I felt I had to wait.” The group expressed a wish that women as mentors and role models had been in greater abundance in previous decades. Dr. Page said she would tell herself, “I’m smart, I’m strong, I can get this done. I’ll be a good surgeon. I don’t need to worry about the judgment that’s being passed on me here.”

The group expressed hope when asked, “Do you believe that we can decrease or come close to eradicating the bullying or harassment in our field?” Dr. Page reminded her colleagues that a core mission of the Ruth Jackson Society is mentoring. “Look at what happened over the past year in the #MeToo movement: People who were silently tolerating harassment finally gave a voice to it.” She said she believes that in a similar way, mentoring in every stage of a woman’s career is imperative for affecting change. Dr. Matzkin observed that awareness will promote caring. Dr. Sabatini commented on the importance of Dr. Weber’s role on the AAOS Presidential Line: “Having an incoming women president, in and of itself, speaks to a new era in orthopaedics, and it is just amazing to be an orthopaedic surgeon at this time and see some of these changes happening.”

Dr. Weber offered a three-pronged approach to harassment and bullying. “I think it is aspirational to completely eradicate it, but we have to try. From a strategy standpoint, first, I believe you have to empower women. So, in whatever ways we can empower women to be resilient, to stay confident—all the tips we’ve been talking about here—that’s important. Number two, we have to educate the profession on implicit bias. We have to make both men and women aware of the downstream effects of implicit bias, and then we have a chance to change the culture. I think this is something that the Academy should get involved in, with an effective educational effort that is easy for people to participate in—so that people can say, ‘Ah-ha, you know, I’ve done or said that before and didn’t realize it had a negative effect on someone else.’ Number three, at all levels, whether in academics or private practice, there needs to be a no-tolerance policy for these cases of actual harassment and bullying.”

Jennifer M. Weiss, MD, is an orthopaedic surgeon specializing in pediatric sports medicine at Kaiser Permanente, Los Angeles Medical Center. She is chair of the AAOS Communications Cabinet.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.

Jennifer M. Weiss, MD, is an orthopaedic surgeon specializing in pediatric sports medicine at Kaiser Permanente, Los Angeles Medical Center. Prior to joining Kaiser Permanente in 2011, she practiced at Children’s Hospital Los Angeles and served as director of the Pediatric Sports Program at the Santa Monica Orthopaedic Group. She previously served as a member of the AAOS Board of Directors and currently is chair of the AAOS Communications Cabinet.

Coleen S. Sabatini, MD, is chief of the pediatric orthopaedic surgery division at UCSF Benioff Children’s Hospital Oakland and has held this position for more than five years. She became a leader early in her young career. Her passion lies in caring for patients throughout the world, especially those who lack the necessary financial and social resources. The pediatric orthopaedic community looks to Dr. Sabatini as an educator and a leader in providing orthopaedic care to the underserved. In the discussion, Dr. Sabatini said that bullying and harassment do exist in the world of orthopaedics, not just for women but for underrepresented minorities and even for majority males who are in subordinate positions. It manifests in a variety of ways, including inappropriate comments and physical contact. “Sometimes, the person who is doing it doesn’t even realize that they’re demeaning or, in some way, making the female orthopaedic surgeon less than their male colleagues, either in terms of how they refer to them or how they treat them or the legitimacy to which they listen to their concerns and suggestions,” she commented.

Elizabeth G. Matzkin, MD, assistant professor at Harvard Medical School, Chief of Women’s Sports Medicine at the Brigham and Women’s Hospital in Boston, and a member of the AAOS Board of Directors, has come to be known in the orthopaedic community as a leader in providing care to athletes, especially female athletes. She is married to Eric Smith, MD, who is also an orthopaedic surgeon specializing in joint arthroplasty. Dr. Matzkin noted that “whenever there is hierarchy there is potential bullying.”

Alexandra Page, MD, is in private practice in San Diego, specializing in foot and ankle surgery. She is the president of the Ruth Jackson Orthopaedic Society. She is known among the women of orthopaedic surgery as a role model and mentor—someone who has led them in understanding how to be an orthopaedic surgeon and a mother at the same time. Her late husband was a pediatric orthopaedic surgeon, respected by his partners and the pediatric orthopaedic community and well-loved by his patients and their families. Dr. Page struck a positive note, saying, “over the course of my career there has been a cultural shift in how women, as physicians, are treated. That is momentum on which we can build, as women have grown to be 50 percent of medical school graduates, even if orthopaedics has lagged behind.”

Kristy L. Weber, MD, is the first vice-president of the AAOS, slated to assume the presidency in 2019, and the first woman to have entered the Academy’s Presidential Line. She is a professor of orthopaedics and chief of Orthopaedic Oncology at the University of Pennsylvania. (Among all medical school faculty, 24 percent of full professors are women; in orthopaedics, the figure is just 9 percent, according to the Association of American Medical Colleges.) Dr. Weber noted that she has seen “egregious examples” of bullying of men and women. She pointed out, in a matter-of-fact tone, that “whenever there is a large, disparate minority group, this behavior is more likely to happen. I think that is the culture that we are in and it needs to change.”