Newly elected AAOS President confronts gender gaps in orthopaedics

I grew up in St. Louis with my brother, participated on the swim team, raised family pets, and played outside more often than inside. I attended public schools through college, and my summers were spent canoeing, backpacking, and developing personal relationships at camps without the distraction of technology. I was a good student and developed a résumé of academic and community activities.

If this personal description was included on an application to an orthopaedic residency program without a picture or other sex-identifying features, it might blend in with the majority of male applicants. Why, then, does a woman with similar experiences or academic achievements to men stand out—and not always in a positive way? For my first column as AAOS president, I can only authentically speak as a woman—and not a woman of color. Women (or men) in racial or ethnic minority groups are viewed even more differently than typical students interested in orthopaedic surgery.

The U.S. population is comprised of 51 percent women, and although medical schools are achieving sex parity, the field of orthopaedic surgery remains in stark contrast. This has led surveys and articles to ask, “Why?”

There was a time when women were not allowed to attend any medical schools or, in 1848, only allowed to attend women’s medical colleges. As a medical student at Johns Hopkins, one of my favorite stories in its rich history was of Mary Elizabeth Garrett, who inherited her family’s B&O Railroad fortune. When Johns Hopkins left $7 million to start a university and hospital in Baltimore, he expected a medical school to be part of the university. The hospital opened in 1889, but no funds remained for the school. Mary, in one of the earliest examples of coercive philanthropy, provided funds for the medical school on the stipulation that a college degree be a prerequisite and that women be admitted on equal terms as men. Times do change, but oh, so slowly.

Now, women are less of an anomaly in orthopaedics. There are more women leaders who serve as examples and role models, as well as robust organizations such as the Ruth Jackson Orthopaedic Society and other sex-focused groups. Women in orthopaedics gather at subspecialty society meetings and commune virtually on social media. I felt the excitement during the AAOS 2019 Annual Meeting opening ceremony as another glass ceiling was broken when I addressed the membership as the Academy’s first female president.

Many academic training programs across the country are now vying for qualified female candidates in orthopaedics and realizing that the competencies between women and men do not differ. However, there are still programs where women are not represented in the resident cohort, whether due to a lack of interest or a track record that does not entice diverse applicants. I believe that training programs without an increasingly diverse resident population will be unsustainable in the long term.

Although there is a higher percentage of women in residency training compared to 10 years ago, our field remains in last place among all surgical specialties, including neurosurgery, urology, and colorectal surgery, which takes the air out of the rationalization that the reason relates to “lifestyle.” There are many opportunities to increase the percentage of women in orthopaedics and change the culture of our field.

Rather than simply hoping that more women will enter orthopaedic residency training and excel in leadership roles, medical schools and orthopaedic departments need to provide meaningful financial support for those efforts. Each training institution can commit to established orthopaedic pipeline programs, including the Perry Initiative (https://perryinitiative.org) and Nth Dimensions (www.nthdimensions.org). Those efforts were founded by women and provide hands-on training and mentoring, respectively, for students. Both programs have impressive track records based on students matching with orthopaedic programs. Funds to create opportunities for female medical students to interact with orthopaedic residents or faculty can help dispel myths about the field. Leadership training for both female and male residents, as well as junior faculty, can facilitate improved skillsets to further allow for advancement in the field. Marked sex disparities will continue without a financial commitment to make a transformational difference.

We also must acknowledge sex biases on individual and institutional/program levels. Implicit bias training on a regular basis (prior to residency selection), with faculty and residents taking one or more modules of the Implicit Association Test (https://implicit.harvard.edu/implicit/takeatest.html), will start the conversation. Take a close look at traditions in your practice or academic setting that subtly disadvantage or disrespect women. Consider renaming “wives’ events,” providing alternate or additional organized inclusive social activities (e.g., alternatives to golf outings), and referring to female and male orthopaedic surgeons in a similar fashion (i.e., referring to a woman by her first name versus a man as “doctor”). Look closely at the requirements for resident advancement or “partner” opportunities in the private practice setting; ensure that they are competency-based and that all individuals are equally advantaged. Finally, childbearing should be supported whether during training or practice. The American Board of Orthopaedic Surgery rules allow resident time off to be averaged over the entire training period. State and institutional rules should be reviewed to consider maternity and paternity leave policies. We need to change our ways to remain relevant in the future.

At an organizational level, AAOS will be guided by its new five-year Strategic Plan. One of the three primary goals states, “Evolve the culture and governance of AAOS’ Board and volunteer structure to become more strategic, innovative, and diverse.” The Academy’s Diversity Advisory Board (DAB) will advise the Board on a five-year strategy for achieving the diversity goal. Sex and racial/ethnic diversity and inclusion are the most obvious disparities in our governance structure, but DAB will recommend an even broader definition and plan for changing the face of our organization.

Kristy L. Weber, MD, is president of AAOS, as well as a professor and vice chair of faculty affairs in the Department of Orthopaedic Surgery at the University of Pennsylvania.