Previous studies have identified several factors that contribute to gender disparities in orthopaedics, including lack of early exposure to musculoskeletal medicine, a paucity of female role models, the challenging lifestyle, male dominance in the field, difficulty maintaining work-life balance, and barriers to promotion. There are also gender disparities in research productivity, which is essential for academic advancement.
Mary Mulcahey, MD, FAAOS, associate professor of clinical orthopaedic surgery and director of the women’s sports medicine program at Tulane University, is the senior author of a recent article published in the Journal of the AAOS ®, which evaluated research productivity among male and female orthopaedic surgeons at academic residency programs. Her team found that, in geographic regions with a greater proportion of female orthopaedic faculty members, women had greater research productivity. Among department chairs, associate professors, and professors, there was no difference in research productivity between male and female academic orthopaedic surgeons. However, among assistant professors, there was a significant difference in research productivity.
Joseph Zuckerman, MD, FAAOS, Walter A.L. Thompson Professor of Orthopaedic Surgery and chair of the Department of Orthopaedic Surgery at NYU Langone Health and previous president of AAOS; Antonia Chen, MD, MBA, FAAOS, director of research of arthroplasty services at Brigham and Women’s Hospital and associate professor at Harvard Medical School; Mary I. O’Connor, MD, FAAOS; professor of orthopaedics and rehabilitation at Yale University School of Medicine; and Regis O’Keefe, MD, PhD, FAAOS, chair of the Department of Orthopaedic Surgery at Washington University School of Medicine, shared their insights on the study results.
Dr. Samora: Why do you think gaps in research productivity exist at more junior levels for female orthopedic surgeons but not at more senior levels?
Dr. O’Keefe: The article by Dr. Mulcahey and colleagues clearly shows that women in programs with higher proportions of female faculty members have greater research productivity. In my experience, this is likely due to two factors. First, the opportunity to have other women as mentors and role models is empowering. The second factor is related to self-selection. Talented women looking for jobs and making career choices are more likely to be attracted to academic programs that have provided women the infrastructure, support, and mentoring necessary for academic productivity. We as a specialty need to provide more opportunity to female surgeons across the board.
Dr. O’Connor: I see three basic reasons for this gender gap: time, mentorship, and goal clarity. Numerous studies show that women still spend more hours on “family and domestic activities” than men. It wasn’t until I was a mother that I understood some of this is, in my opinion, rooted in biology. When my children were small and got up in the middle of night, they never woke up my husband. They wanted mom. They were oblivious to whether I had a big day of surgery ahead. There is simply more balancing that moms need to do, and that is challenging. And the data show that dads need to do more at home, too. Second, mentorship is critical to provide guidance and academic opportunity, and Dr. Mulcahey’s research suggests that this occurs more often when there are more female faculty. Finally, in my experience, junior female faculty may not have defined “where they want to be in 10 years” as clearly as male junior faculty. There is opportunity for coaching here.
What factors influence this finding?
Dr. Zuckerman: I think this is the continued impact of being in a predominantly male specialty at both resident and faculty levels. Our residency is now comprised of 26 percent women, which should help correct this disparity. However, it needs to be combined with an awareness of the disparity and a focus on making certain that equal opportunities are provided to the female residents. Steps should also be taken to address the disparity by making certain that equivalent opportunities are available to female faculty members. This is even more important because it is research productivity, as the article points out, that is essential for progression in one’s academic career. Resources are needed to close this gap. It is important to recognize that the needs of female junior faculty members may be different than the needs of male junior faculty members. Family responsibilities, including motherhood, generally have a greater impact on female faculty members than their male counterparts. Therefore, necessary accommodations must be made so female faculty receive the same support for the development of their academic careers.
Dr. O’Keefe: We need to be intentional in our mentoring of all junior faculty, but particularly of women faculty members. Often, mentoring occurs informally, with junior faculty within subspecialty divisions aligning with senior faculty and obtaining resources that lead to publications, productivity, and promotion. Ensuring that women have access to clinical coordinators, career development programs, and research funding is essential, but it is not enough. As a chair, I strive to ensure that my female junior faculty feel comfortable talking to me about challenges and perceived disparities, which are difficult conversations for all involved. The goal is to make all junior faculty—men and women—feel that they are receiving adequate mentoring, resources, and opportunities. Recognizing the existence of implicit bias is difficult, but essential in achieving this goal.
Have you counseled younger/junior male and female colleagues on research, getting published, grants, etc.?
Dr. Zuckerman: I provide the same advice to all junior faculty members. I emphasize that the first five years of one’s academic career are most important for developing a foundation for academic productivity and future growth. It is essential that junior faculty who want to develop an academic career be in a situation that provides the support (both time and resources) for this to occur. It is an important factor to consider when an individual decides which position to accept.
Dr. O’Connor: One of the first questions I ask any mentee is what their career goals are, both short and long term. Who are their mentors? Have they leveraged these relationships to advance their goals? What is their area of interest that gives them the best opportunity for national recognition? What are their barriers to research? Often, the first steps are the hardest, and discussing the smaller steps can make a difference. When I was at Mayo Clinic, we created a program to bring female faculty together and created theme-based research groups so they could support each other and get published. Often, this started with a review paper that would evolve into retrospective clinical research. It was a great start for junior women.
Dr. O’Keefe: The most rewarding thing about being a chair is seeing young faculty members develop and contribute as academic leaders. I have individual research/academic development meetings with all junior faculty members twice per year where we discuss their current research projects and progress, as well as challenges. As chair, I endeavor to connect faculty members with investigators or programs at the department, institutional, or national level that can contribute to their success.
Research productivity is often tied to promotion and tenure, as well as job opportunities. How can the discrepancy in research productivity at more junior levels be corrected to close the gap in career opportunities for women in orthopaedics and medicine?
Dr. Zuckerman: This is a self-selecting phenomenon. As faculty progress to more senior levels, the emphasis on research productivity will vary. Some maintain the same high level of productivity, while it becomes much less important for others and their productivity decreases significantly. Maintaining research productivity requires commitment. However, this commitment is a two-way street. The individual has to be committed to continued research productivity, and their program has to be committed to continued support. Support can be defined in many ways but can be summarized as creating an environment that is conducive to academic growth. If that environment can be created, it will be up to each individual to make the most of the opportunities.
Dr. O’Connor: Resources are important to promote productivity. I believe that expectations are as well. Chairs who mentor junior faculty with defined academic goals for each individual are more likely to see productivity. I believe this is particularly important for young female faculty to help them stay focused on early productivity.
Dr. O’Keefe: It is important that faculty understand the promotion process and discuss it with their chairs. Department chairs have a great deal of influence on the process, and it is important that women advocate as strongly as men for their promotions. Faculty often have the sense that there is a specific number of papers that are required for promotion. This is not the case at most institutions, and there is a large degree of subjectivity involved in the process. In some cases, women become involved in service roles and committees that advance the mission of the department, and it is essential that these activities are recognized and accounted for in the promotion process.
There are only five female chairs of orthopaedic surgery in the United States. Why is this?
Dr. Chen: When it comes to being chair of a department, there are many factors that are involved. First, there needs to be a desire to be chair. Some men or women aspire to be chair, and others do not. It is possible that women may not aspire to be orthopaedic department chairs, although this has never been substantiated by evidence. Secondly, it helps to be mentored, sponsored, coached, and encouraged to become chair. It is possible that men may be more encouraged than women to become leaders, especially if they expressed an interest to be a chair. Finally, similar to the problem with female orthopaedic residents, we are likely to model those whom we see. If we don’t see many female orthopaedic chairs, we are less likely to have more of them.
Dr. O’Connor: As a prior department chair, my perspective is perhaps unique. Leadership style and unconscious bias remain factors in the promotion of women to top leadership positions—not just in orthopaedics but in all of medicine and business. Women tend to be more collaborative in their leadership style, and this is not always valued as highly. We still have unconscious bias that for a woman to be a leader she must be really tough. That implies in our subconsciousness that she is not a warm person. We see her as competent but not as likeable. Just look at female political leaders such as Hillary Clinton or Kamala Harris. We see them as competent and tough, but do not typically perceive them as warm or likeable. This also disadvantages our fantastic (and warm) women leaders in orthopaedics.
Julie Balch Samora, MD, PhD, MPH, FAAOS, is a pediatric hand surgeon at Nationwide Children’s Hospital in Columbus, Ohio, and deputy editor of AAOS Now. She can be reached at firstname.lastname@example.org.
- Hoof MC, Sommi C, Meyer LE, et al: Gender-related differences in research productivity, position, and advancement among academic orthopaedic faculty within the United States. J Am Acad Orthop Surg 2020. [Epub ahead of print]