The theme of the Florida Orthopaedic Society (FOS) Annual Scientific Meeting that took place June 20–23 was “Celebrate Diversity in Orthopaedics.” AAOS President Kristy L. Weber, MD, noted during her vice presidential address at the AAOS 2018 Annual Meeting that orthopaedics is the least diverse of all specialties. She said that the U.S. orthopaedic workforce has only 6.1 percent women and 4.8 percent underrepresented minorities. Furthermore, orthopaedic residencies are still the least diverse of all specialties, with only 12 percent to 15 percent females.
At the FOS meeting, incoming FOS President David R. Chandler, MD, MHL, reviewed the FOS mission, vision, and strategic goals. FOS President Brett R. Bolhofner, MD, and the FOS Board of Directors created the strategic goals in 2006, which included: (1) promoting the delivery of culturally competent care, and (2) supporting efforts to diversify the profession and the orthopaedic workforce.
In his 2018 FOS Presidential Acceptance Speech, Dr. Chandler charged FOS to address these strategic goals and embrace diversity by developing an inclusive, respectful culture that encourages participation in orthopaedics by all demographics.
The FOS Board accepted the diversity challenge, and during the Florida Medical Association 2018 Annual Meeting, FOS moved to begin a FOS Diversity Task Force ad hoc committee. The task force established a creative space to generate ideas FOS could enact to achieve its goal and promote culturally competent patient care.
The FOS Diversity Task Force enlisted several contributing members, including Sonya Ahmed, MD; Odion Binitie, MD; Lisa Cannada, MD (chairperson); Dr. Chandler; Sheila Conway, MD; Jennifer Hagen, MD; Jason Oberste, MD; Eddie Powell, MD; and Vani Sabesan, MD. The task force also included Randall Morgan, MD, who is a founding member of the J. Robert Gladden Society. Dr. Sabesan was a driver of the Diversity Task Force and the FOS Annual Meeting Program Committee chairperson. In those positions, Dr. Sabesan was focused the committee and designed the annual meeting to highlight the efforts of the Diversity Task Force.
The FOS Diversity Task Force tasked Fraser Cobbe and the FOS administrative team with obtaining statistics on sex, ethnic, and racial diversity in Florida. An assessment of FOS membership and data on Florida orthopaedic surgeons from the Florida Agency for Health Care Administration revealed that Florida had 6.47 percent female orthopaedic surgeons, following national benchmarks for sex; however, society membership had less than the national average at 4.35 percent females (Table 1).
Women and minorities lack representation in orthopaedics
FOS data on Florida orthopaedic surgeons and society membership indicated significant disparities for those identifying as black or Latino.
Correction of the inequalities will take a long time, requiring evaluation and improvement of the orthopaedic workforce pipeline. Women represented 58 percent of undergraduates in 2012 and 47 percent of medical students in 2014, but only 14 percent of orthopaedic residents and 6 percent of AAOS active fellows in 2014.
Mary O’Connor, MD, director of the Center of Musculoskeletal Care at the Yale School of Medicine, wrote about how medical school experiences influence women’s interest in orthopaedic surgery and highlighted that early access to orthopaedics and role models were significant. Many men develop an interest in orthopaedics before their clinical rotations, but both women and minorities exhibit an increased application rate to orthopaedics if their medical school curricula have a required orthopaedic clinical rotation.
Contributing to the low participation of women in orthopaedic training programs is the lack of female faculty role models. Orthopaedic residencies have only 13 percent women, the lowest of all specialties, and only 3.8 percent female full-time professors.
Another barrier for female applicants is poor perceptions of orthopaedics, including negative attitudes toward women, male dominance in the profession, lifestyle difficulties with career-family balance, physical demands, acceptance by senior faculty, and diminished opportunities for promotion.
Women are more likely to be asked illegal questions during their residency interviews, and women are much less likely to rank a program when asked such questions during an interview.
Social media postings provide additional insights to the sex-biased culture of orthopaedics. Threads with the theme “women in orthopaedics” include such entries as “Orthopaedics is physically demanding, and one needs to be strong,” “Orthopaedics is an ‘old boys’ network,” “‘Girly girls’ won’t ﬁt in and need not apply,” and “The orthopaedic lifestyle is bad and not conducive to a satisfying personal life.”
Dr. Cannada shared information from the Royal Australasian College of Surgeons (RACS): While in neurosurgical training in Australia, Caroline Tan, MD, reported sexual harassment by an attending physician. A court ruled in her favor with an award of $100,000, but it was difficult for her to secure employment at any public hospital in Australia. Gabrielle McMullen, MD, an Australian senior vascular surgeon, publicly commented during an ABC interview: “What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request. The worst thing you could possibly do is to complain to the supervising body, because then, as in [Dr. Tan’s] position, you can be sure that you will never be appointed to a major public hospital.” Her revelation created a public outcry. RACS was so alarmed by the incident and allegation that it created an Expert Advisory Group (EAG) to investigate. The EAG determined that there was widespread discrimination, bullying, and sexual harassment within the surgical community in Australia. The recommendations to correct the behaviors centered on culture and leadership, education, and management of complaints.
During her presidential speech at the AAOS 2019 Annual Meeting, Dr. Weber discussed pervasive bias. She cited a 2018 survey of 5,600 AAOS members that assessed work culture; it found that “more than 50 percent of male and female respondents experienced discrimination and bullying, and more than 50 percent of women experienced sexual harassment in their roles as orthopaedic surgeons.”
Making improvements for the future
FOS aims to leverage opportunities in leadership, education, and culture. Furthermore, the organization decided to follow the Donabedian model of quality improvement by creating structures to facilitate processes to generate outcomes with metrics to apply to ongoing improvements in structures and processes.
To address leadership, FOS proposed an amendment to its bylaws to create a Diversity Committee as a permanent voting position on the Board. The amendment was distributed to the FOS membership and passed at the 2019 Annual Scientific Meeting. The incoming president appoints the diversity chair and approves Diversity Committee members. The committee will continue the creative space for its members to generate innovative ideas to advance racial, ethnic, and sex inclusion and diversity in the Florida orthopaedic workforce and to promote culturally competent care of musculoskeletal patients in the state. The diversity chair will bring forward the ideas of the committee to the Board and hold the Board accountable on relevant topics and communication. FOS is very proud that the 2019–2020 Board is the most diverse in FOS history.
To address educational gaps, Drs. Sabesan and Binitie volunteered to provide lectures to medical schools, including Florida International University and the University of South Florida, and initial feedback has been positive. FOS also may approach the Florida legislature to seek legislation requiring orthopaedic rotations during the clinical years of medical schools to improve female and minority application rates to orthopaedic residencies. FOS seeks to partner with the Ruth Jackson Society, the J. Robert Gladden Orthopaedic Society, and AAOS, as well as the National Diversity Council and the Florida Diversity Council. Members of the Diversity Task Force also have discussed working with other foundational efforts such as Nth Dimensions and the Perry Initiative.
Changing culture is more problematic. As Peter Drucker noted in his book, “Culture eats strategy for breakfast.” Culture is more pervasive and challenging, as one must address not only explicit markers and public behaviors but also implicit beliefs and biases. FOS hopes that the presence of a Diversity Committee chair on the Board will help evolve its leadership culture, and the FOS Diversity Task Force has discussed periodical implicit association testing of the FOS Board as a metric to monitor progress. Cultural change in orthopaedics is not something that can be accomplished by one group of people; it demands the participation of all. In his book, Allan G. Johnson stated, “As long as we participate in social systems, we do not get to choose whether to be involved in the consequences that result. We are involved because we are here. As such, we can only choose how to be involved, whether to simply be a part of the problem or to also be part of the solution. That is where our power lies, and our responsibility.”
FOS inclusion and diversity efforts have had a modest beginning, but the organization is committed to sustaining and accelerating change. The FOS Diversity Committee invites Florida orthopaedists and other state orthopaedic societies to invest in improving the orthopaedic culture to strengthen our profession and enhance cultural competence in the care of our patients.
David R. Chandler, MD, MHL, is an orthopaedic spine surgeon in practice at the Andrews Institute for Orthopaedics and Sports Medicine in Gulf Breeze, Fla. He is past president of FOS.
- Baldwin K, Namdari S, Bowers A, et al: Factors affecting interest in orthopedics among female medical students: a prospective analysis. Orthopedics 2011;34:e919-32.
- Bucknall V, Pynsent PB: Sex and the orthopaedic surgeon: a survey of patient, medical student and male orthopaedic surgeon attitudes towards female orthopaedic surgeons. Surgeon 2009;7:89-95.
- Surgeons.org: Expert Advisory Group on Discrimination, Bullying, and Sexual Discrimination. Available at: https://www.surgeons.org. Accessed July 25, 2019.
- Hill JF, Yule A, Zurakowski D, et al:. Residents’ perceptions of sex diversity in orthopaedic surgery. J Bone Joint Surg Am 2013;95:e1441-6.
- Johnson AG: Privilege, Power, and Difference. 3rd ed. New York, NY: McGraw-Hill Education; 2018.
- Lewis VO, Scherl SA, O’Connor MI: Women in orthopaedics—way behind the number curve. J Bone Joint Surg Am 2012;94:e30.
- O’Connor MI: Medical school experiences shape women students’ interest in orthopaedic surgery. Clin Orthop Relat Res 2016;474:1967-72.
- Stanton T: Kristy L. Weber, MD, Begins Her Term as AAOS President. Available at: https://www.aaos.org/aaosnow/2019/May/Cover/cover01/. Accessed July 18, 2019.
- Walker P: Australian Senior Surgeon Attacked for Remarks on Sexual Harassment. Available at: https://www.theguardian.com/australia-news/2015/mar/09/australian-senior-surgeon-gabrielle-mcmullin-attacked-sexual-harassment. Accessed July 18, 2019.