Jo A. Hannafin, MD, PhD, FAAOS, a past gold medalist in crew, rows her craft on Long Island Sound.
Courtesy of Jo A. Hannafin, MD, PhD, FAAOS

AAOS Now

Published 7/27/2021
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Terry Stanton

Jo A. Hannafin, MD, Speaks about Implicit Bias in Orthopaedics

Sports medicine trailblazer evaluates recent progress and identifies remaining challenges

In the mid-1990s, Jo A. Hannafin, MD, PhD, FAAOS, and Lisa R. Callahan, MD, her primary care sports medicine partner at Hospital for Special Surgery (HSS), perceived something missing in HSS’ sports medicine program: the availability of care specific to the needs of female athletes of all ages. To address this shortcoming, the pair founded the HSS Women’s Sports Medicine Center. Given the status of women’s sports medicine at that time, they encountered pushback along the way.

Although the state of care available to women who engage in athletics and exercise has improved since the not-so-distant time when the duo founded the HSS woman-focused center, even now the implicit biases reflected in the bewildered reaction to its very need persist.

Jo A. Hannafin, MD, PhD, FAAOS, a past gold medalist in crew, rows her craft on Long Island Sound.
Courtesy of Jo A. Hannafin, MD, PhD, FAAOS
Jo A. Hannafin, MD, PhD, FAAOS, (right) offers instruction during a procedure at Hospital for Special Surgery. She recently retired from clinical practice but continues to be involved with the academic programs at HSS.
Courtesy of Jo A. Hannafin, MD, PhD, FAAOS

Dr. Hannafin the center’s cofounder and current director, recalled hearing, “Why do we need a center for women?” Her response: “We found that women, particularly those who were post-collegiate athletes in their 30s or 40s, were not getting appropriate care. People would infer and often imply that, now that they were done with college sports, they no longer needed to exercise.” The mature athletes were often told they “should stop running and playing sports that caused symptoms.”

As one may suspect, upon opening the center, Dr. Hannafin recalled, “We found that female patients came to see us because they needed someone who reflected their own gender and would accept the fact that, even at 30, they might want to exercise on a regular basis.”

Dr. Hannafin related this story in a talk titled “Implicit Bias: How It Affects Our Profession and Our Patients” that she delivered as the 2021 John G. Kennedy, MD, FRCS(C) Memorial Lectureship at the joint virtual Specialty Day of the Arthroscopic Association of North America and the American Orthopaedic Society for Sports Medicine (AOSSM) in March.

Deep roots

Biases commonly arise, often at an early age, from family, media, and other influences that “shape who we will be as adults,” Dr. Hannafin said. “Whether positive or negative, these cognitive shortcuts can result in prejudgment that may lead to rash decisions or discriminatory practice.”

Implicit bias is not restricted to those “who are deliberately prejudicial,” she observed. “They reside deep in our subconscious and develop over a lifetime of experiences from an early age.” Dr. Hannafin cited the words of Lisa Suleiman, MD, FAAOS, an arthroplasty surgeon who serves as Director of Diversity and Inclusion at the McGaw Medical Center of Northwestern University: “Categorizing people without realizing it is as natural as breathing.”

In medicine, the negative effects of implicit bias can be particularly problematic when they result in errors or omissions in patient care, Dr. Hannafin said. Implicit bias can also exist on the patient side, she noted.

“Clear data show that many patients will opt to see a physician of a similar race, gender, or background because of the perception that they will receive better care,” she said. Dr. Hannafin added that she sometimes is on the receiving end of the bias: “At the end of a thorough exam, MRI review, and discussion of the need for surgery, a patient will ask me, ‘Who will do my surgery?’ Their implicit bias is that I am a female and maybe shouldn’t be doing their surgery. I simply respond that I will be doing it, and the response is almost uniformly favorable.”

Where white and male prevail

Orthopaedic surgery remains one of the least diverse specialties in medicine, Dr. Hannafin noted. About 94 percent of its practitioners are male and 86 percent are white. Dramatic change is not in the immediate offing, as 15 percent of current orthopaedic residents are female.

Those who teach and train future orthopaedic surgeons reveal a similarly nondiverse makeup, with faculty, program chairs, and department heads dominated by white men.

Assumptions and stereotypes, including among young people who aspire to be physicians, perpetuate the situation. “As first-year medical students, we would look around the lecture hall to predict which of our classmates would become surgeons, psychiatrists, or pediatricians,” Dr. Hannafin recalled.

The predictions she and her classmates made were often based “on our own exposure and stereotypes,” she said. “The stereotype of the classic orthopaedic surgeon is the medical student who played college football and then goes on to a career in medicine.”

In her case, however, the stereotypes were wrong. “No one would have predicted that the skinny, nerdy scientist and lightweight rower would ultimately become a sports medicine surgeon,” said Dr. Hannafin, who competed at the highest level in crew as a three-time gold medalist at U.S. National Rowing Championships and was a member of the 1984 Silver Medalist Lightweight Double at the World Rowing Championships. Until recently, she served as longtime team physician for USRowing as well as for the WNBA New York Liberty and has served as a role model for female orthopaedic surgeons in sports medicine—including in her term as the first woman president of the AOSSM in 2013–2014.

Dr. Hannafin tackled the larger question pertaining to inclusiveness in orthopaedic surgery: “How did we get here and how do we expose a diversity of people to our incredible profession?” Part of the answer, she said, is opening mindsets and expanding perceptions of the individuals who may excel as orthopaedic surgeons. “We tend to think of athletes as very suited for orthopaedic surgery because they understand teamwork,” she said. “I would suggest that someone who plays in an orchestra and maybe was not a recruited athlete also has fine motor skills and may have the same approach to teamwork that someone who plays a high school or collegiate sport has.”

The question is urgent in orthopaedics, Dr. Hannafin said, and calls for “awareness and action” to change the situation. She noted that early on, medical students “are negatively and positively impacted by what they see and hear.” In the negative category are the all-male panels—or “manels”—that “are incredibly common at national meetings.”

A factor that hinders diversity and inclusiveness is “a lack of sponsorship of women and minorities.” Dr. Hannafin urged her colleagues to provide true engagement in promoting young physicians.

“Sponsorship is very different from mentorship and is important to increase diversity in academic and professional leadership positions,” she explained. “We need to nominate and sponsor our younger faculty members who come from diverse backgrounds to speak at meetings, to be involved in instructional courses; we need to sponsor them for society committees and nominations for leadership positions. At your own institutions, sponsor them for promotion within an academic institution.”

Dr. Hannafin offered advice on how one may make a meaningful contribution to promoting diversity and overcoming unconscious internal biases. “Increasing opportunities with diverse people helps to mitigate implicit bias,” she said. “Reach out to different individuals within your institution, through your diversity committee or medical students you work with to try to diminish your stereotyping and increase the opportunities for your own personal change as you meet other people who are not like you.”

She closed her presentation with a display of the AOSSM Diversity and Inclusion Statement, which concludes that pursuing diversity and inclusion is central to the society’s mission of “transforming mind, body, and spirit.” Dr. Hannafin concluded that a commitment to these principles “is going to help all of our members deliver the best possible care to all communities.”

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