A 15-Year Report on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States

The Association of Cannabis and Tobacco Use With Postoperative Complications after Ankle and Hindfoot Arthrodesis

Background

The purpose of this study was to investigate the association between cannabis use and postoperative complications following ankle and hindfoot arthrodesis.

Methods

A retrospective cohort study using a large national insurance database from 2010 to 2022 was conducted. All patients who underwent ankle or hindfoot arthrodesis with at least 2 years' follow-up were included. Patients were divided into 4 groups: cannabis-only users, tobacco-only users, cannabis and tobacco users, and nonuser controls. Groups were matched 1:4 with nonuser controls based on demographic variables and comorbidities. Also, both cannabis and tobacco users were matched 1:4 with tobacco-only users based on demographics and comorbidities. Medical complications within 90 days of surgery and surgery-specific complications within 2 years were compared between groups with multivariable logistic regressions.

Results

Compared with nonuser controls, cannabis users only were not at increased risk of 90-day medical complications or 2-year surgical complications. Tobacco use alone was associated with increased risk of postoperative admission (OR 1.32, 95% CI 1.21-1.43) and emergency department (ED) utilization (OR 1.57, 95% CI 1.48-1.66) within 90 days as well as infection (OR 1.24, 95% CI 1.18-1.30), hardware removal (OR 1.12, 95% CI 1.07-1.18), nonunion (OR 1.33, 95% CI 1.27-1.40), and wound dehiscence (OR 1.38, 95% CI 1.27-1.49) within 2 years of surgery compared with nonuser controls. Compared with tobacco-only use, combined cannabis and tobacco use was associated with increased risk of ED visits within 90 days (OR 1.45, 95% CI 1.30-1.62) and nonunion within 2 years of surgery (OR 1.19, 95% CI 1.05-1.35).

Conclusion

These findings suggest that although cannabis use alone was not associated with a higher risk of postoperative complications, its concurrent use with tobacco was linked to greater rates of adverse outcomes.

Level of Evidence

Level III, retrospective case control study.

Breaking the Glass Ceiling: Female Speaker Representation at the American Orthopaedic Foot & Ankle Society Annual Meetings Over Time

Background

Female representation among residents and practicing surgeons in orthopaedics remains disproportionately low at 19.3% and 7.4%, respectively. This study investigates female representation in speaker roles at American Orthopaedic Foot & Ankle Society (AOFAS) meetings over time.

Methods

The annual AOFAS meeting programs for 2012 to 2024 were reviewed by 3 independent raters. Each speaker, moderator, and panelist was classified based on gender and role; data were cross-checked using Fleiss multirater κ validation. Sessions discussing surgical or biomedical topics were categorized as "technical," and all other sessions were categorized as "nontechnical." Yearly odds ratios (ORs) and CIs evaluating gender vs session status, as well as gender vs speaker role, are provided.

Results

A total of 2396 speaking sessions were analyzed; 11.5% of sessions were led by female speakers. Over time, female speaker representation ranged from 5.61% in 2014 to 18.75% in 2022. Female speakers led only 10.8% of the 2088 technical sessions. On average, female speakers were significantly more likely than males to assume nontechnical speaking roles across all years combined (OR 1.5111, 95% CI 1.0792-2.1158, P = .0162). For individual year ORs, female speakers were significantly more likely to assume nontechnical speaking roles in 2020 (OR 12.24, 95% CI 4.082-36.67, P < .001); however, the differences were not statistically significant for other years. Females also comprised 10.10% and 12.00% of moderator and panelist roles, respectively.

Conclusion

Female speaker involvement was representative of AOFAS female membership and the national population of female orthopaedic surgeons. Additionally, our study revealed an increasing trend in female speakers, panelists, and moderators from 2012 to 2024. However, there is a need for a shift in the distribution of speaker roles to prevent professional marginalization. Continued efforts to support female representation as role models at national conferences increases visibility and may help to address the lack of women within orthopaedics.

Level of Evidence

Level III, retrospective cross-sectional study.

Representation Matters: A Higher Percentage of Women Orthopaedic Surgery Faculty Is Associated With an Increased Number of Women Residents

INTRODUCTION

Orthopaedic surgery has been recognized as one of the least diverse surgical specialties. Previous studies have demonstrated that women are heavily underrepresented within orthopaedic surgery. The purpose of this study was to determine whether orthopaedic surgery residency programs with a higher presence of women faculty had a higher proportion of women residents.

METHODS

The Fellowship and Residency Electronic Interactive Database was used to identify all orthopaedic surgery residency programs in the United States. Resident and faculty's sex and degree were recorded in addition to faculty administrative title (eg, program director, chair) and academic rank (clinician, professor, etc). Pearson correlation coefficients were used to compare the number of women residents with the number of women faculty.

RESULTS

A total of 192 orthopaedic surgery programs were analyzed. Of the 5,747 faculty members and 4,268 residents identified, 13.1% (n = 752) and 22.6% (n = 963) were women, respectively. The number of women residents markedly correlated with the number of women faculty in leadership positions (r = 0.516, P < 0.001), such as chief or chair. The most significant correlations were among women with the academic role of "professor" (r = 0.575, P < 0.001), "assistant professor" (r = 0.555, P < 0.001), and women who held faculty positions but held no higher academic appointment (r = 0.509, P < 0.001). Program directors and assistant program directors were not found to have significant correlations with the number of women residents.

CONCLUSION

This study demonstrates a positive correlation between women faculty and residents at orthopaedic surgery residencies. Some academic positions, such as division chief, held more significant associations, whereas other positions, such as professor emeritus, were not held by any women, thereby limiting statistical analysis. Further investigation into minority representation in orthopaedic surgery and initiatives to address the observed disparities is paramount.

Considerations to Optimize Structurally Responsive Work Environments for U.S. Military Specialty Physicians

INTRODUCTION

Recruitment, training, and retention of wartime critical specialty physicians may be stymied by discrimination and abuse. It is unclear to what extent the US combat specialty physicians witness or experience discrimination and abuse, whether they or others intervene, and if they would subsequently discourage people from entering their field.

MATERIALS AND METHODS

The present study surveyed US active duty anesthesiologists, emergency medicine physicians, and orthopedic surgeons (N = 243; 21% response rate). A generalized linear model evaluated the extent to which gender, specialty, service, and number of witnessed/experienced negative/stigmatizing comment/event types were associated with burnout. A bootstrapped mediation analysis evaluated whether gender and burnout were mediated by the number of comment/event types.

RESULTS

The sample was majority non-Latine White (87%) and men (66%) with tri-service and specialty representation. The most commonly reported negative/stigmatizing comment/event types were related to pregnancy (62%) and parental leave (61%), followed by gender and assigned sex (42%), lactation (37%), and sexual harassment (35%). Of the respondents who witnessed/experienced such comments/events, self-intervention was reported after comments regarding lactation (43%), assigned sex and gender (42%), race and ethnicity (41%), pregnancy (41%), parental leave (37%), and sexual harassment (24%). Witnessing another person intervene was reported after sexual harassment (25%) and comments/events regarding race and ethnicity (24%), pregnancy (20%), assigned sex and gender (19%), lactation (19%), and parental leave (18%). Nonintervention was reported after comments/events related to parental leave (42%), pregnancy (38%), sexual harassment (26%), lactation (26%), assigned sex and gender (26%), and race and ethnicity (22%). Respondents reported moderate-to-high intervening likelihood, importance, and confidence. Respondents reporting neutral to extremely agree on prompts indicating that pregnant active duty physicians are trying to avoid deployment (P = .002) and expect special treatment that burdens the department (P = .007) were disproportionately men (36% and 38%, respectively) compared to women (14% and 18%, respectively). The highest proportion of neutral to extremely agree responses regarding discouraging specialty selection were reported in relation to transgender and gender diverse students (21%), followed by cisgender female students (18%); gay, lesbian, or bisexual+ students (17%); cisgender male students (13%); and racial and ethnic minoritized students (12%). In the primary model, the number of witnessed/experienced comment/event types was associated with greater burnout (0.13, 95% CI 0.06-0.20, P = .001), but women did not report significantly different levels of burnout than men (0.20, 95% CI -0.10 to 0.51, P = 0.20). The number of comment/event types mediated the relationship between gender and burnout (0.18, 95% CI 0.06, 0.34; P < .001).

CONCLUSIONS

Although reported intervening confidence, likelihood, and importance were high, it is unclear whether perceptions correspond to awareness of intervention need and behaviors. Bivariate differences in burnout levels between men and women were fully explained by the number of comment types in the mediation model. Annual trainings may not effectively address workplace climate optimization; institutions should consider targeted policy and programmatic efforts to ensure effective, structurally responsive approaches.

The Women in ORTHopaedics Program Offers Early Exposure to Orthopaedic Surgery for Young Women. A Pre- and Post-Event Survey Comparison

Background

In recent years, the medical field has made significant progress toward promoting gender equality. Despite this progress, orthopaaedic surgery remains the least diverse specialty among other surgical specialties. In response, our Department of Orthopaedics developed a specialized orthopaedic curriculum, Women in ORTHopaedics (WORTH), tailored specifically for young women in high school. This program offers early exposure and mentorship opportunities within the orthopaedic field.

Methods

Participants were asked to complete a preliminary survey prior to the workshop. Subsequently, a corresponding survey was administered following the workshop, mirroring the questions from the pre-event survey. Participants shared their impressions of orthopaedics, interest in pursuing a career in this field, and awareness of available career pathways within this specialty.

Results

In both workshops, the consensus among participants in the pre-event surveys included a sense of novelty and a desire to learn more about orthopaedics. However, post-workshop responses revealed a shift in perceptions, with participants expressing that orthopaedics encompasses a much broader array of subjects than initially expected. A comparison between pre- and post-survey responses indicates a heightened interest in pursuing a career in orthopaedics following the workshop. Additionally, 100% of attendees expressed their intention to participate in future WORTH events.

Conclusions

Findings indicate that WORTH played a constructive role in guiding young women toward trajectories beyond secondary education. Additionally, it provided insights into the multitude of career options available in Orthopaedics apart from surgery, including physiotherapy, occupational therapy, nursing, research, and biomedical engineering.

Key Concepts

(1)Early exposure and mentorship allow for increased representation and retention of women in orthopaedics.(2)Representation of women in orthopaedics improves patient care and contributes to a more holistic approach to healthcare.(3)Outreach initiatives influence participants' interest and perceptions of pursuing a career in orthopaedics.

Level of Evidence

Level IV.

The Impact of Sustained Outreach Efforts on Gender Diversity in Orthopaedic Surgery

BACKGROUND

Orthopaedic surgery is one of the least gender-diverse surgical specialties, with only 7% women in practice and 20.4% in residency. There are numerous "leaks" in the talent pipeline for women orthopaedic surgeons that lead to the field as a whole falling short of a critical mass (30%) of women. For over a decade, a network of professional and nonprofit organizations, including the Ruth Jackson Orthopaedic Society, The Perry Initiative, Nth Dimensions, and others, have focused on targeted outreach and mentoring of women in the talent pipeline; they report a positive effect of these interventions on recruitment and retention of women in the field.

METHODS

In this study, we applied mathematical models to estimate the historic and future impacts of current outreach and hands-on exposure efforts to recruit more women into orthopaedic surgery. The model uses published data on program reach and impact from one of the largest and longest-running programs, The Perry Initiative, and combines it with AAMC and AAOS Census data. These data were used to forecast the percentage of women entering the profession as postgraduate year 1 (PGY1) residents and among practicing orthopaedic surgeons.

RESULTS

The results of the mathematical models suggest that the increase in women in the PGY1 population from 14.7% to 20.9% from 2008 to 2022 is at least partially attributable to current mentoring and outreach efforts by The Perry Initiative and others. Assuming continued intervention at present levels, the PGY1 residency class will reach peak diversity of 28% women in 2028, and the field as a whole will reach a steady-state composition of approximately 25% practicing women orthopaedic surgeons by 2055.

CONCLUSIONS

The results of this study indicate that outreach and exposure efforts, such as those of The Perry Initiative, are having a substantive impact on gender diversity in orthopaedic surgery. With continued intervention, the field as a whole should approach a critical mass of women within a generation. The collective efforts of the orthopaedics community over the past decade to close the gender gap serve as a guidebook for other professions seeking to diversify.

Gender Disparity in Authorship Among Orthopaedic Surgery Residents

Background

Gender disparity remains pervasive in orthopaedic surgery, which affects the research pursuits of orthopaedic surgeons. The purpose of this study was to characterize gender-related authorship trends of orthopaedic surgery residents, including evaluation of gender-concordant publication rates.

Methods

An observational cross-sectional analysis of US orthopaedic surgery residency programs was performed. Information on residency programs and demographics of each cohort was collected. Publication metrics consisting of number of first and non-first author publications and H-indices were manually obtained for PGY-3 to PGY-5 residents attending the 25 programs ranked the highest for research output by Doximity. Gender of each resident and senior author was determined from institutional websites using photos, biographies, and preferred pronouns when available.

Results

A total of 532 residents, 169 (31.8%) female and 363 (68.2%) male, were included for authorship analysis. Of them, 415 (78%) had at least one first author publication, which did not vary significantly by gender. Female residents had disproportionately fewer first author publications compared with their representation (22% vs. 31.8%, p < 0.00001). Female residents averaged fewer first and non-first author publications compared with male residents (2.8 vs. 4.6, p = 0.0003; 6.4 vs. 10, p = 0.0001 respectively). Despite fewer publications overall, a greater subset of publications by female residents were written in collaboration with a female senior author compared with publications by male residents (p < 0.0001). Male residents had a higher average H-index of 5.4 vs. 3.9 among female residents (p = 0.00007).

Conclusion

Despite similar rates of first author publication among male and female residents, female residents had fewer publications overall, lower H-indices, and disproportionately fewer first author publications than would be expected given their representation. Findings from this study suggest that gender disparity in orthopaedic surgery extends to differences in research productivity as early as in residency. This may have negative implications on the career advancement of female orthopaedic surgeons. Additional work is needed to identify and understand biases in research productivity and career advancement, to promote more equitable strategies for academic achievement.

Level of Evidence

IV.

Is There Gender Disparity in Orthopedic Surgery Resident Research Productivity?

Background: Compared with male senior authors, female senior authors publish less often in orthopedic journals than expected based on their population proportion. It is unknown whether this trend is also present among orthopedic trainees. Purpose: We sought to determine whether there is a gender discrepancy in the publication volume and authorship status among orthopedic residents. Methods: We conducted a cross-sectional analysis to evaluate the research productivity of male and female orthopedic residents. The top 10 ranked US orthopedic surgery residencies by research output in 2021-2022 were obtained from Doximity. Residents' names were recorded from each institution's residency website. We classified each resident as male or female, searched on PubMed, and recorded the number of publications relevant to orthopedic surgery. Resident contribution to each publication was recorded as either a first/last author or a middle author. To assess contributions by postgraduate year, we compared male and female junior residents (PGY1-3) and senior residents (PGY4-5) using the number of total publications, middle author publications, first/last author publications, and the difference between the number of middle and first/last author publications. Results: Among the 335 male and 117 female residents included, male residents had more total publications than female residents. Among PGY4-5, male residents had more total publications and middle author publications. There was no difference in the number of first/last author publications between male and female PGY4-5 residents. Conclusions: Our cross-sectional analysis found that in the 2021-2022 academic year, male orthopedic surgery residents published more often than female residents, although among PGY4-5 residents, we found no gender differences in number of first/last author publications. The difference in total publications among PGY4-5 residents is likely due to differences in middle author publications. Future research should consider residents' self-identified gender, including non-binary and gender-fluid identity.

Gender Disparities in Endowed Professorships Within Orthopaedic Surgery

Background Orthopaedic surgery has the lowest number of full-time faculty positions held by women, at 19%, with endowed chairs among the most coveted and advantageous. We examined the characteristics of endowed professors from the US top 100 orthopaedic academic centers and highest-funded musculoskeletal (MSK) researchers to determine if gender is associated with endowed professorship. Additionally, we sought to determine if gender is associated with increased NIH funding for top-performing musculoskeletal researchers.  Methods Our primary study group included the top 100 orthopaedic academic centers defined by US News World Report and Doximity's rankings. Our secondary study group examined the top MSK researchers, defined as principal investigators, who received >$400,000 in annual NIH funding from 2018 to 2021. Orthopaedic departments included MSK researchers and subspecialties within orthopaedics and medicine. Publicly available sources were used to compile institutional, gender, H-index, citation number, and subspecialty data on endowed professors; statistical comparisons were calculated. Results Within the top 100 orthopaedic academic departments, 4674 faculty were identified. Seven hundred and thirty-three (15.68%) were identified as women, 3941 as men (84.32%). One hundred and ninety-four held endowed professorships; 13 were awarded to women (6.7%), and 185 (95.3%) were awarded to men, with a significant odds ratio (OR) of 2.95, favoring men. For MSK researchers, the OR increases to 11.4. Arthroplasty and sports had the highest numbers of endowments. Significant differences in H-index, publications, and graduation year were identified between men and women for top MSK researchers and orthopaedic-trained surgeons; however, these differences disappeared when considering heterogenous orthopaedic departments that included medicine subspecialties, plastic surgery, hand surgery, and neurosurgery. Additional gender differences were observed in endowment names, with awards commemorating 51.5% men, 7.2% women, and 34% families or groups. Conclusion Gender inequities at the endowment level are substantial, and there are very few women in musculoskeletal medicine to achieve endowments. Differences in H-index, publications, and graduation year between men and women MSK researchers and orthopaedic-trained surgeons, but not combined orthopaedic, PM&R, and medical subspecialty departments, suggest unique challenges in orthopaedic surgery environments and histories that may contribute to endowment disparity. Gender was not found to be associated with funding bias for top-performing musculoskeletal researchers.

Inequalities in the Evaluation of Male Versus Female Athletes in Sports Medicine Research: A Systematic Review

BACKGROUND

Female sports participation continues to rise; however, inequalities between male and female athletes still exist in many areas and may extend into medical research.

PURPOSE

The purpose of this study was to (1) compare the number of published studies evaluating male versus female athletes in various sports and (2) identify which co-ed sports currently underrepresent female athletes in the sports medicine literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

All nonreview research studies published from 2017 to 2021 in 6 top sports medicine journals were considered for inclusion. Sports medicine studies were included that isolated athletes, reported study outcomes specific to male and/or female patients, provided study outcomes for specific sports, and evaluated ≤3 different sports. The total number of studies reporting on male and/or female athletes were compared for all sports, and odds ratios (ORs) were calculated. Comparisons of study design, level of sports participation, outcomes assessed, and study quality were also made according to participant sex.

RESULTS

Overall, 669 studies were included the systematic review. Most studies isolated male athletes (70.7%), while 8.8% isolated female athletes and 20.5% included male and female athletes. Female athletes were more frequently studied in softball and volleyball, while male athletes were more commonly researched in baseball, soccer, American football, basketball, rugby, hockey, and Australian football. Notably, male athletes were largely favored in baseball/softball (91% vs 5%; OR = 18.2), rugby (72% vs 5%; OR = 14.4), soccer (65% vs 15%; OR = 4.3), and basketball (58% vs 18%; OR = 3.2).

CONCLUSION

Sports medicine research has favored the evaluation of male athletes in most sports, including the majority of co-ed sports. Potential reasons for this inequality of research evaluation include availability of public data and database data, financial and promotional incentives, a high percentage of male sports medicine clinicians and researchers, and sex biases in sport. While the causes of these differences are multifaceted, researchers should consider both sexes for study inclusion whenever possible, and journals should support a more balanced representation of research publications regarding male and female athletes.

Persistent Lack of Female Orthopaedic Sports Medicine Fellows

Purpose

To evaluate the gender composition of fellows, faculty, and leaders within orthopaedic sports medicine fellowship programs to provide a more complete description of gender diversity within this subspecialty.

Methods

Official program websites of orthopaedic sports medicine fellowships listed on the Arthroscopy Association of North America fellowship directory were examined. Data collected for analysis included the gender of program directors, fellowship faculty, orthopaedic surgery department faculty, current sports medicine fellows, and fellows who graduated within the last 5 years.

Results

Of the 132 orthopaedic sports medicine fellows in training in the United States in the 2021 to 2022 academic year, 113 (85.6%) were men and 19 (14.4%) were women (P < .001). Within the past 5 years, 419 fellows were listed as completing a sports medicine fellowship, with 375 (89.5%) being men, and 44 (10.5%) being women (P < .001). There was no significant difference in the gender composition of current fellows compared with the composition of fellows within the last 5 years (P = .74). When we examined gender trends in sports medicine faculty, 639 (86.6%) were men and 99 (13.4%) were women (P < .001). There were 14 women (14.4%) orthopaedic sports medicine faculty in leadership positions (i.e., program director or assistant program director) compared with 83 men in such positions (85.6%) (P < .001).

Conclusions

Orthopaedic sports medicine fellowships remain heavily male-dominated on all levels, including fellows, faculty, and leadership. There were no differences in the gender composition of current fellows when compared with those who graduated in the last 5 years, suggesting persistent gender disparity and the need for novel initiatives to enhance gender diversity in sports medicine.

Level of Evidence

IV, descriptive study.

Persistent Lack of Female Orthopaedic Sports Medicine Fellows

PURPOSE

The purpose of this study was to evaluate the gender composition of fellows, faculty, and leaders within orthopaedic sports medicine fellowship programs to provide a more complete analysis of gender diversity within this subspecialty.

METHODS

Official program websites of orthopaedic sports medicine fellowships listed on the Arthroscopy Association of North America (AANA) fellowship directory were examined. Data collected for analysis included the gender of program directors, fellowship faculty, orthopaedic surgery department faculty, current sports medicine fellows, and fellows who graduated within the last five years.

RESULTS

Of the 132 orthopaedic sports medicine fellows in training in the United States in the 2021-2022 academic year, 113 (85.6%) were men and 19 (14.4%) were women (p<0.001). Within the past five years, 419 fellows were listed as completing a sports medicine fellowship, with 375 (89.5%) being men, and 44 (10.5%) being women (p<0.001). There was no significant difference in the gender composition of current fellows compared to the composition of fellows within the last 5 years (p=0.74). When examining gender trends in sports medicine faculty, 639 (86.6%) were men and 99 (13.4%) were women (p<0.001). There were 14 women (14.4%) orthopaedic sports medicine faculty in leadership positions (i.e., program director or assistant program director) compared to 83 men in such positions (85.6%) (p<0.001) CONCLUSIONS: Orthopaedic sports medicine fellowships remain heavily male-dominated on all levels, including fellows, faculty, and leadership. There were no differences in the gender composition of current fellows when compared to those who graduated in the last five years, suggesting persistent gender disparity and the need for novel initiatives to enhance gender diversity in sports medicine.

A Decade's Perspective on the Orthopedic Workforce in Saudi Arabia

Background The orthopedic surgery workforce constitutes a vital role in the healthcare system, with data being scarce. Therefore, through this study, we share an overview of the orthopedic workforce distribution, demographic trends, and changes over the past decade in Saudi Arabia. Methods All practicing orthopedic surgeons in Saudi Arabia from January 1, 2010, to December 31, 2021, were included in the study. Data regarding orthopedic surgeons' demographics and numbers were obtained from the Saudi Commission for Health Specialties (SCFHS), whereas the data related to the geographical distribution of orthopedic surgeons was obtained from the Ministry of Health Statistical Yearbook of 2020. Results The ratio of orthopedic surgeons per 100,000 people was 5.42 in 2010, which grew subsequently to 12.29 in 2021. The number of Saudi orthopedic surgeons has been noticeably rising through the years, while a slowly growing pattern can be seen among non-Saudi orthopedic surgeons. In addition, the highest ratios of orthopedic surgeons per 100,000 were in Makkah (1.72), Riyadh (1.26), and the Eastern Region (1.06). Conclusion In this study, we demonstrate the progress of the orthopedic workforce in Saudi Arabia over a period of 12 years. The number of orthopedic surgeons per 100,000 people showed a significant rise due to several factors, one of which is road traffic accidents. Also, although the number of female orthopedic surgeons has been rising lately, they are still much fewer than males in this field. In addition, Saudi Arabia has been developing a new healthcare system via the privatization of some of the governmental hospitals, which will lead to changes in the future workforce and its accommodations.

Female Authorship in the US Orthopaedics Literature: A Bibliometric Analysis of Trends

INTRODUCTION

Although orthopaedic surgery continues to be the field with the smallest proportion of women, efforts have been made to increase the gender diversity in the workforce. Some data exist on how this increased female representation manifests itself in research and authorship. However, a comprehensive overview-beyond general orthopaedics journals and including subspecialty journals-is currently missing. The objective of this study was to analyze female authorship trends in four high-impact general orthopaedic journals and the highest impact journal in each orthopaedic subspecialty.

METHODS

This bibliometric analysis extracted original research articles published from groups within the United States from Medline from January 2011 to December 2020. We included four high-impact general orthopaedic journals and the highest impact journal in eight orthopaedic subspecialties. Authors' gender was determined using the 'gender' R package. We assessed annual proportion of female authors in first authors, last authors, and any author, separately for all included articles and stratified by journal. Authorship was assessed by Cochran-Armitage trend tests.

RESULTS

There has been increasing female authorship from 2011 to 2020 for female first authors, but not female last authors or total authorship. Of the journals studied, 3 of 12 had a markedly increased percentage of female first authors and 1 of 12 had a markedly increased percentage of female last authors, and there were no journals with an increasing total amount of female total authors.

DISCUSSION

The increasing trend in female authorship is primarily due to increases in first author publications and is not consistent across subspecialty journals. Future research should identify driving factors for these differences and potential methods to increase representation.

Making the Case for Diversity

Orthopaedic surgery lags behind all other medical specialties in its representation of women and underrepresented minorities. Diversity in medical training enhances the educational experience, improves cultural sensitivity, promotes professionalism, and increases the number of physicians who will provide care to the underserved. Diversity of the healthcare workforce leads to enhanced communication, greater patient satisfaction, improved care, better outcomes, and fewer healthcare disparities. Although pediatric orthopaedic surgery has demonstrated recent increases in diversity in the field, there remain opportunities to create a workforce that better reflects our patient population. Key Concepts•We remain a homogeneous specialty.•Diversity of teams and organizations has multiple benefits.•Diversity in healthcare enhances education, patient care, and outcomes while decreasing disparities.•It is imperative to maintain a physician workforce that better reflects the U.S. population.

Recruitment of the Next Generation of Diverse Hand Surgeons

Hand surgery encompasses a diaspora of pathology and patients, but the surgeons treating this population are not commensurately diverse. A physician population that reflects the population it treats consistently leads to improved patient outcomes. Despite increasing diversity amongst surgeons entering into pipeline specialties such as General Surgery, Plastic Surgery, and Orthopaedic Surgery, the overall makeup of practicing hand surgeons remains largely homogenous. This article outlines organizations, such as the Perry Initiative, which have increased recruitment of women and underrepresented minorities into pipeline programs. Techniques of minimizing bias and increasing opportunities for underrepresented groups are also discussed.

Correlations Between Department and Training Program Online Presence and Women in Orthopedic Surgery Training

Background

Orthopedic residency programs increasingly use websites and social media to reach students. This accelerated during the COVID-19 pandemic, especially as away rotations became limited. Women remain a minority of orthopedic residents, and there are no data that indicate the correlation between department/program website content or social media presence on the gender diversity of residency classes.

Methods

Orthopedic department websites were assessed between June 2021 and January 2022 to identify program director's gender, as well as the gender composition of the faculty and residents. Instagram presence for the department and/or program was also identified.

Results

There was no correlation found between the residency program director's gender and the gender diversity of residents in a given program. The percentage of women faculty identified on a department website was significantly correlated with the percentage of women residents in the program, regardless of the program director's gender. While there was an increase in the percentage of women residents among programs with Instagram accounts for the class that started in 2021, this was negated when the percentage of women faculty was taken into account.

Conclusion

Efforts on multiple fronts will be needed to increase the number and percentage of women applying for and training in orthopedic surgery. Given the increasing use of digital media, we need a better understanding of what information, including faculty gender diversity, can be conveyed through this format that is useful for women medical students interested in orthopedic surgery to address their concerns about the field.

The other side of conflict: Examining the challenges of female orthopaedic surgeons in the workplace

BACKGROUND

As more women begin to enter the traditionally male-dominated field of orthopaedics, it is critical to examine their experiences in navigating gender-based conflicts in the workplace.

METHODS

An anonymous survey was distributed via a web link to approximately 1,100 members of Ruth Jackson Orthopaedic Society (RJOS) and 1,600 members of Women in Orthopaedics (WIO) Facebook group, with an estimated response rate of 50% and 50% respectively and protocols to mitigate duplicate response. Questions included demographics and presented several workplace scenarios.

RESULTS

Of the 373 respondents, 72% described experiencing some type of workplace conflict self-attributed to being female. Additionally, 8% reported either being forced out or leaving their previous job due to workplace conflict, leading to depression, anxiety, and burnout. 17% of respondents would not choose the same career again if given the opportunity.

CONCLUSIONS

Workplace conflict diminishes a surgeon's career satisfaction and may ultimately contribute to burnout. Understanding the relationship between gender bias and orthopaedic surgery is essential in moving towards change, and addressing these issues will create a more positive working environment for female surgeons.

Patient Initiated Discrimination and Harassment-A Descriptive Survey of Experiences Within a Single Academic Department

Background

Diversity in orthopedics is lacking despite ongoing efforts to create a more inclusive workforce. Increasing diversity necessitates recruitment and retainment of underrepresented providers, which involves representation among leadership, mentorship initiatives, and development of a safe work environment. Discrimination and harassment behaviors are prevalent within orthopedics. Current initiatives aim to address these behaviors among peers and supervising physicians, but patients are an additional underrecognized source of these negative workplace behaviors. This report aims to establish the prevalence of patient-initiated discrimination and harassment within a single academic orthopedic department and establish methods to reduce these behaviors in the workplace.

Methods

An internet-based survey was designed using the Qualtrics platform. The survey was distributed to all employees of a single academic orthopedic department including nursing staff, clerks, advanced practice providers, research staff, residents/fellows, and staff physicians. Survey was distributed on two occasions between May and June of 2021. The survey collected information on respondent demographics, experience with patient-initiated discrimination/harassment, and opinions regarding possible intervention methods. Fisher exact test was used for statistical analysis.

Results

Over one half of survey respondents report observing or personally experiencing patient-initiated discrimination within our orthopedics department (57%, n=110). Nearly half of respondents report observing or personally experiencing patient-initiated harassment within our department (46%, n=80). Encounters with these behaviors were more commonly reported from resident and staff female physicians. The most frequently reported negative patient-initiated behaviors include gender discrimination and sexual harassment. Discordance exists regarding optimal methods to address these behaviors, but one third of respondents indicate potential benefit from visual aids throughout the department.

Conclusion

Discrimination and harassment behaviors is common within orthopedics, and patients are a significant source of this negative workplace behavior. Identification of this subset of negative behaviors will allow us to provide patient education and provider response tools for the protection of orthopedic staff members. Ideally, minimizing discrimination/harassment behaviors within our field will help create a more inclusive workplace environment and allow continued recruitment of diverse candidates into our field. Level of Evidence: V.

Publication and Career Trends of Ruth Jackson Orthopaedic Society Grant Winners Over the Past Decade

Background

The Ruth Jackson Orthopaedic Society awards the Jacquelin Perry, MD Resident Research Grant and RJOS/Zimmer Biomet Clinical/Basic Science Research Grant to female orthopedic surgeons, intending to aid women in the progression and completion of their orthopedic research and bolster their pursuit or current career in academic orthopedic surgery. The impact of these grants has not yet been studied. The purpose of this study is to determine the percentage of scholarship/grant-winners who went on to publish the findings of their research, pursue academic positions, and currently hold positions of leadership in the field of orthopedic surgery.

Methods

The titles of the winning research projects were searched in PubMed, Embase, and/or Web of Science to ascertain publication status. For each award recipient, the number of publications prior to the award year, number of publications after the award year, total number of publications, and H-index were calculated. Each award recipient was searched online through the websites of their employment and social media pages to determine their residency institution, whether they pursued a fellowship, the number of fellowships they pursued, their subspecialty within orthopedics, their current job, and whether they are in academic or private practice.

Results

Of the fifteen Jacquelin Perry, MD Resident Research Grant winners, 73.3% of awarded research projects have since been published. 76.9% of award winners currently work in an academic setting and are affiliated with a residency program, and 0% currently hold leadership positions in orthopedic surgery. Of the eight winners of the RJOS/Zimmer Biomet Clinical/Basic Science Research Grant, 25% have published the findings of their awarded grant. 87.5% of award winners currently work in academics, and 75% hold leadership positions in orthopedic surgery.

Conclusion

Our results show that many of the winners of the Jacquelin Perry, MD Resident Research Grant and RJOS/Zimmer Biomet Clinical/ Basic Science Research Grant have published their research findings, continued research within the field of orthopedic surgery, and pursued academic careers and leadership positions. Many of the barriers to career progression and entry into orthopedic surgery that women and underrepresented groups face could be overcome through more grant opportunities and mentorship. Level of Evidence: V.

Current Gender Diversity and Geographic Trends Among Orthopaedic Sports Medicine Surgeons in the United States

BACKGROUND

Female representation varies geographically among orthopaedic residency programs, with the southern region of the United States reported as having relatively lower rates of female orthopaedic surgeons.

PURPOSE

To determine the gender and geographic distributions of US-based orthopaedic sports medicine surgeons and analyze geographic patterns between their training locations and present-day practices.

STUDY DESIGN

Cross-sectional study.

METHODS

American Orthopedic Society of Sports Medicine (AOSSM) fellowship completion data from the 2016-2021 academic years were analyzed with regard to gender and fellowship location. Medical school, residency, and current practice locations were obtained via internet searches for all individuals identified within the databases. Locations were categorized into regions based on the US Census Bureau definitions. Descriptive statistical analysis was performed on the data.

RESULTS

A total of 1268 sports orthopaedic surgeons who graduated fellowship from 2016 to 2021 were analyzed: 141 (11%) were female and 1127 (89%) were male. The percentage of female sports medicine surgeons in fellowship remained constant (11%-12%) from 2016 to 2021. On average, the annual percentage of female orthopaedic sports medicine fellows was 7.2% in the South, 10.4% in the West, 14.2% in the Midwest, and 14.7% in the Northeast. Based on the orthopaedic sports medicine fellowship graduates from 2016 to 2021, the mean percentage of current female orthopaedic sports medicine surgeons in practice was 7.4% in the South, 11.7% in the Northeast, 12.8% in the Midwest, and 14.4% in the West.

CONCLUSION

Approximately 11% of our sample was female; however, this percentage varied heavily by region, with the southern region having significantly lower rates of gender diversity.

Fellowship and future career plans for orthopedic trainees: gender-based differences in influencing factors

Objective

Understanding gender-based preferences and factors influencing fellowship and subspecialty choice might help maximize gender diversity in orthopedic surgery. This study aims to identify the differences between male and female orthopedic trainees' future career plans. It also examines the factors and determinants that influence selection of fellowship specialties in Saudi Arabia.

Methods

This cross-sectional multicenter study recruited orthopedic surgical trainees from multiple training centers. The survey was completed by 270 participants; 20 residents were excluded because they were unsure of their future career interests or preferred fellowships in general orthopedic practice. The participants were either postgraduate orthopedic residents or fellows who already enrolled in postgraduate residency and/or fellowship training program. A total of 201 (80% of 250 participants) were male and 49 (20%) were female.

Results

The orthopedic subspecialities and fellowship preferences and their influencing factors varied considerably across genders. Pediatric orthopedics and hand and upper extremity were top sub-specialties preferences among women while arthroscopy and sports medicine, arthroplasty, and trauma were the top preferences among men. Women preferred to practice single subspeciality while men preferred to do multiple fellowships and practiced different orthopedic subspecialities. The expected income, private-sector job opportunities, and hospital needs were the most significant factors influencing subspecialty and future career preferences among men while personal interest and social and family commitments were the most influential factors for women.

Conclusions

This study addresses the knowledge gap regarding gender-based subspecialty preferences and the factors influencing them. The results can inform strategy development for addressing women’s needs and interests in orthopedic surgery as well as the shortages of orthopedic surgeons in some subspecialties. Furthermore, these data may assist directors of training centers in analyzing expected future demands on fellowship training programs and addressing the training gap in all subspecialties and career counseling.