AAOS Now

Published 4/1/2019
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Terry Stanton

Study Published in JAAOS Probes Factors in Residency Application Rates Among Females

Although women now comprise half of all graduating medical students, orthopaedic surgery lags considerably in the number of women in its practice ranks.

Alana M. Munger, MD, a first-year orthopaedic surgery resident at Yale School of Medicine, and her colleagues reported on the factors that may influence female students when they are selecting a residency specialty. Their study of this critical decision point appears in the April 15 edition of the Journal of the AAOS (JAAOS). Specifically, the study focused on trends in the proportion of female applicants to orthopaedic surgery residency programs and the presence of female faculty in orthopaedic surgery at a large number of academic institutions. The study examined data from 101 U.S. medical schools over a nine-year period. The study included a total of 130,803 medical school graduates, of whom 48.41 percent were female. In the study group, the percentage of female applicants increased from 13.91 percent in 2005–2006 to 16.02 percent in 2013–2014. At the same time, the percentage of female faculty increased from 12.26 percent in 2005–2006 to 15.79 percent in 2013–2014. Over the entire period, a total of 6,637 medical school graduates applied to orthopaedic surgery residency programs, of whom 14.57 percent were female.

A total of 2,341 orthopaedic faculty members were reported in 2005–2006 and 3,135 in 2013–2014. Of those, 12.26 percent were female in 2005–2006 and 15.79 percent were female in 2013–2014, representing a 3.53 percent increase. Over the same period, the number of female instructors increased from 51 to 76, the number of female assistant professors increased from 150 to 270, the number of female associate professors increased from 65 to 98, and the number of female professors increased from 21 to 51. Over the same period, 31 medical schools (30.7 percent) did not have any female faculty in at least one of the nine years examined, and four medical schools (4.0 percent) did not have any female faculty in all nine years examined. The number of programs without any female faculty in orthopaedic surgery decreased from 22 (21.8 percent) in 2005–2006 to seven (6.9 percent) in 2013–2014.

The study’s most important finding, according to Dr. Munger, lead author, is that no correlation was found between the average number of female faculty members at an institution and the total number of female applicants to the same institution.

The role of role models

Explaining how she came to undertake the study, Dr. Munger recalled her recent personal experience choosing orthopaedics as a career. During her first year in medical school, she was unaware that orthopaedics was “the least [sex]-diverse field in medicine.” After hearing numerous colleagues remark on the lack of women in surgery, particularly orthopaedic surgery, she decided to investigate further. “My subsequent literature review revealed numerous factors dissuading female medical students from entering orthopaedic surgery, including perceived toughness requiring physical strength, male-dominated culture, unfavorable lifestyle due to long hours, [sex] discrimination, maltreatment and decreased acceptance by residents and faculty, inadequate exposure to musculoskeletal curriculum, and a lack of same-[sex] role models,” she said. “The importance of same-[sex] role models was repeatedly emphasized throughout my literature review. Therefore, I sought to create a study that would objectively evaluate the association between female faculty and female residency applicants.”

Dr. Munger said the results of the study are consistent with prior investigations demonstrating an underrepresentation of women in faculty positions at medical schools. “However, what was surprising was that we failed to demonstrate the relationship between female faculty and female applicants to orthopaedic surgery,” she said. “Although there are limitations of the study that need to be considered when interpreting the results, this finding challenges the importance of same-[sex] role models for orthopaedic surgery applicants.”

Another surprise, Dr. Munger said, was found in the correlation analysis between female applicants and female faculty by faculty position (instructor, assistant professor, associate professor, and full professor). The positive relationship between female residency applicants and female assistant professors would suggest that assistant professors have a more positive influence on recruiting female medical students. “This may either indicate that they spend more time with female residency applicants or they are more effective in mentorship and inspiring female medical students to pursue a career in orthopaedic surgery,” she said.

Also of note was the negative relationship between residency applicants and full professors—which, according to Dr. Munger, raises a question: Are full professors dissuading female medical students from pursuing orthopaedic surgery? “Again, although there are limitations that certainly need to be considered when interpreting the results of the study, the findings of the investigation raise some questions regarding the importance of same-[sex] role models for residency applicants,” she said.

Understanding the gap

The “good news” about the issue of women in orthopaedic surgery is that there has been a significant amount of research investigating the topic, Dr. Munger said. Poon et al., recently examined data from the American Association of Medical Colleges and noted that although the percentage of female orthopaedic surgery residents increased from 10.9 percent to 14.4 percent between 2006 and 2015, the rate of increase was significantly lower compared to other specialties (JAAOS, January 2019). Additionally, Camp et al., recently found that female orthopaedic surgery residency applicants demonstrated more grit, consistency of interest, and conscientiousness than their male colleagues (JAAOS, March 2019). “These investigations are a few examples of the recent literature that has effectively raised awareness and increased our knowledge regarding the gender gap in orthopaedic surgery.”

A shift is needed in the focus of future investigations, Dr. Munger said. “We know that there has been an inability to recruit female applicants into orthopaedic surgery. We know that the rate of increase in the percentage of female residents is lower in orthopaedic surgery [than] other specialties. We know the factors that dissuade female medical students from entering the field. Now is when we investigate which strategies or outreach programs are effective in recruiting female medical students.”

The following are pertinent questions:

  • Do we need to develop a musculoskeletal curriculum that can be distributed to medical schools across the country?
  • Do our national organizations need to organize regional events for female surgeons to encourage mentorship and foster career development?
  • Do we need to develop a mentorship curriculum to ensure female faculty members have the knowledge and skills to successfully recruit female medical students?
  • Most importantly, how can we objectively determine whether the strategies are effective in recruiting women into the field?

“It’s an exciting time for women in orthopaedic surgery,” Dr. Munger said. “I am eager to see where we go from here.”

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

References:

  1. Poon S, Kiridly D, Mutawakkil M, et al: Current trends in sex, race, and ethnic diversity in orthopaedic surgery residency. J Am Acad Orthop Surg 2019.
  2. Camp CL, Wang D, Turner NS, et al: Objective predictors of grit, self-control, and conscientiousness in orthopaedic surgery residency applicants. J Am Acad Orthop Surg 2019;27:e227-34.

Author’s note: Lattanza et al., demonstrated that women who participated in the Perry Initiative’s Medical Student Outreach Program demonstrated a match rate of 31 percent in the first graduating class and 28 percent in the second graduating class. The authors noted that the percentages are twice the current percentage of female orthopaedic surgery residents.3 Mason et al., noted that women who completed the Nth Dimensions/AAOS Orthopaedic Summer Internship Program had increased odds of applying to orthopaedic surgery residency programs.4 One should applaud those outreach efforts, but we also must recognize that the number of women who inevitably participate in those programs is limited.

  1. Lattanza LL, Meszaros-Dearolf L, O’Connor MI, et al: The Perry Initiative’s Medical Student Outreach Program recruits women into orthopaedic residency. Clin Orthop Relat Res 2016;474:1962-6.
  2. Mason BS, Ross W, Ortega G, et al: Can a strategic pipeline initiative increase the number of women and underrepresented minorities in orthopaedic surgery? Clin Orthop Relat Res 2016;474:1979-85.