Racial and Sex Disparities in Resident Attrition in Orthopaedic Surgery

Women in Irish orthopaedics - A review of female representation at the Irish Orthopaedic Association annual meeting over a 16-year period

INTRODUCTION

There is underrepresentation of women in orthopaedics worldwide. As of 2017, 10 % of Irish orthopaedic consultants and 12.24 % of higher specialist trainees were female. Workplace diversity can promote innovation, creativity, and encourage staff retention. To realise these benefits, it is quoted that there must be 30 % minority representation. We examine the representation of women in academic orthopaedics in Ireland by looking at gender breakdown at the Irish Orthopaedic Association (IOA) annual conference.

METHODS

IOA programmes from 2008 to 2023 were examined assessing for representation of women. Non-consultant hospital doctors (NCHD's), session chairs and guest speakers were examined. Linear regression analysis for male and female speakers was performed to evaluate for statistical significance.

RESULTS

Fourteen annual conferences were evaluated equating to 740 NCHD-delivered oral presentations. Women delivered 126 presentations (17.03 %). While there was a general trend of increasing female representation over the years examined, linear regression analysis did not show this to be statistically significant (Coefficient: 0.3746, P-value: 0.077, R2: 0.237). There was a statistically significant decline in male speakers (Coefficient: 1.9775, P-value: 0.007, R2: 0.473). 41 guest lectures were delivered, 14.63 % by women. Session chairs were disclosed for 7 meetings equating to 54 sessions presided over by 79 chairs. Six chairs were female (7.59 %).

CONCLUSION

Orthopaedics is likely to be better served by more diverse workforces that are representative of their populations. Our study highlights that while gender disparity persists in Irish academic orthopaedics, there appears to be a shift towards diversity. This is particularly evident at trainee level over the past 7 years; however, efforts should be made to support these into leadership roles where women are currently underrepresented. Their visibility can then serve as inspiration for future female trainees.

Sex Diversity in the Emerging United States Arthroplasty Workforce Is Limited

BACKGROUND

Sex diversity remains limited in the United States arthroplasty workforce. This study evaluates fellowship program characteristics associated with increased sex diversity in US-based fellowship programs and the pipeline of women trainees before arthroplasty fellowship.

METHODS

Demographic data from 233,981 allopathic medical school graduates, 11,364 orthopaedic surgery residents, and 1,501 arthroplasty fellows were analyzed. Women trainee representation was calculated among allopathic medical students, orthopaedic surgery residents, and arthroplasty fellows (2012 to 2022). Fellowship program characteristics associated with increased sex diversity among arthroplasty fellows were evaluated with Chi-square tests.

RESULTS

Female representation in arthroplasty fellowship training (5.9%) was less than that in orthopaedic surgery residency (15.1%) and allopathic medical school (47.6%) training (P < 0.001). Sex diversity in arthroplasty fellowship training increased over the study period (2.4 to 9.9%, P < 0.001). The presence of women faculty, geographic region, accreditation status, annual number of fellows, and total number of faculty were not associated with increased sex diversity of arthroplasty fellows (P > 0.05).

CONCLUSIONS

Sex diversity in arthroplasty fellowship training has improved over the past decade. Yet, women trainees remain under-represented relative to the trainee pipeline. Increased efforts to recruit female medical students and orthopaedic residents may help promote workforce diversity in arthroplasty.

Barriers and facilitators for female practitioners in orthopaedic training and practice: a scoping review

BACKGROUND

Despite advances in medical education and professional opportunities, orthopaedic surgery remains the least gender-diverse medical specialty, with women significantly underrepresented globally. This scoping review aims to synthesize existing literature to provide a comprehensive overview of the barriers and facilitators encountered by females in orthopaedic surgery training and practice.

METHODS

A comprehensive search of Medline (OVID), Scopus, Embase, Emcare, and CINAHL was performed from inception to 14 July 2024. Additional sources were identified via citation searching and Google Scholar. Any primary studies employing qualitative, quantitative, or mixed methods approaches to explore barriers and facilitators experienced by female orthopaedic trainees and consultants in high-income countries. Quality analysis of included articles was conducted using the Mixed Methods Appraisal Tool.

RESULTS

Seventy-nine studies met the inclusion criteria, involving over 100 000 participants between 1993 and 2024. Most studies were cross-sectional surveys. Sixty-eight barriers and 38 facilitators were identified. Analysis using the Socio-Ecological Model revealed the complex interplay of factors at the individual, interpersonal, organizational, community, and policy levels. The largest proportion of barriers and facilitators resided at the organizational level.

CONCLUSION

This scoping review provides a comprehensive mapping of current evidence on barriers and facilitators for female practitioners in orthopaedic surgery training and practice. The findings suggest the need for multifaceted interventions to promote gender equity. Future research should evaluate the effectiveness of specific interventions and develop strategies to support women in orthopaedics, ultimately contributing to a more inclusive and diverse workforce.

Inclusive mentorship of pediatric trainees: pediatric oncology as a microcosm

Mentorship is a critical part of career development for medical professionals. Mentees find value in mentors who share parts of their identity, and this role-modeling improves career development. In pediatric hematology-oncology specifically - reflective of academic medicine more broadly - the current pool of mentors is less diverse than the pool of mentees. Mentoring consciously in an inclusive manner is a way to support all mentees, not just those who share identity with the mentor. Utilizing skills such as microintervention and bystander intervention, all while focusing on allyship are tools that mentors can develop and use to improve their mentoring practices.

The correlation between trainee gender and operative autonomy during trauma and orthopaedic training in Ireland and the UK

Aims

The aim of this study was to explore differences in operative autonomy by trainee gender during orthopaedic training in Ireland and the UK, and to explore differences in operative autonomy by trainee gender with regard to training year, case complexity, index procedures, and speciality area.

Methods

This retrospective cohort study examined all operations recorded by orthopaedic trainees in Ireland and the UK between July 2012 and July 2022. The primary outcome was operative autonomy, which was defined as the trainee performing the case without the supervising trainer scrubbed.

Results

A total of 3,533,223 operations were included for analysis. Overall, male trainees performed 5% more operations with autonomy than female trainees (30.5% vs 25.5%; 95% CI 4.85 to 5.09). Female trainees assisted for 3% more operations (35% vs 32%; 95% CI 2.91 to 3.17) and performed 2% more operations with a supervising trainer scrubbed (39% vs 37%; 95% CI 1.79 to 2.06). Male trainees performed more operations with autonomy than female trainees in every year of training, in each category of case complexity, for each orthopaedic speciality area, and for every index procedure except nerve decompression. When adjusting for year, training level, case complexity, speciality area, and urgency, male trainees had 145% (95% CI 2.18 to 2.76) increased odds of performing an operation with autonomy and 35% (95% CI 1.25 to 1.45) increased odds of performing an operation under trainer supervision, than assisting, compared to female trainees.

Conclusion

Male trainees perform more operations with autonomy during orthopaedic training than female trainees. Female orthopaedic trainees assist for a greater proportion of cases than their male counterparts. A comprehensive review of trauma and orthopaedic training is needed to identify any additional differences in training opportunities between female and male trainees, particularly with regard to progression through training.

Assessing the Experiences of Sexual and Gender Minority Applicants to Orthopaedic Surgery Residency

Introduction

The rate of sexual and gender minority (SGM) orthopaedic surgeons is far less than in other specialties, and the field has, in part, had significant difficulty attracting SGM applicants. To provide a more welcoming environment, identifying where applicants experience discrimination along medical training must be of paramount concern. Our objective was to understand the challenges faced by SGM medical students applying into orthopaedic surgery.

Methods

An anonymous survey was sent to applicants of a single orthopaedic residency program in 2023, soliciting demographics, exposure to lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) mentors, and experiences with discrimination. Data were stratified by sexual orientation, and univariate analysis was conducted using chi-squared tests. Afterward, logistic regressions adjusted for gender, age, and race were performed.

Results

The overall response rate was 15.4% (n = 136/881). Fifteen percent (n = 20/135) identified as LGBTQ. Sixty-one percent of LGBTQ-identifying applicants experienced slurs and/or hurtful comments during orthopaedic rotations and research experiences, compared with 28% of their heterosexual peers (p < 0.001). In adjusted logistic regression models, LGBTQ respondents were 3.8 times more likely to report experiencing a hostile environment during training (p = 0.04) and 4.9 times more likely to have reported facing discrimination (p = 0.04) compared with heterosexual participants. Approximately 58% of respondents reported never having interacted with an LGBTQ-identifying orthopaedic attending, with only 5% reporting frequent interaction.

Conclusion

LGBTQ-identifying orthopaedic surgery applicants experience barriers related to their sexual identity, including derogatory comments, hostile clinical environments, and lack of LGBTQ mentorship. These findings highlight challenges inherent to the residency application process that may disproportionately affect persons from sexual minority groups. The recognition of such challenges can help to optimize the establishment of informed policies regarding mistreatment and practices regarding diversity and inclusion.

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.

Barriers to Black Medical Students and Residents Pursuing and Completing Surgical Residency in Canada: A Qualitative Analysis

BACKGROUND

The limited available data suggest that the Canadian surgical workforce does not reflect the racial diversity of the patient population it serves, despite the well-established benefits of patient-provider race concordance. There have been no studies to date that characterize the systemic and individual challenges faced by Black medical students in matching to and successfully finishing training in a surgical specialty within a Canadian context that can explain this underrepresentation.

STUDY DESIGN

Using critical qualitative inquiry and purposive sampling to ensure sex, geographical, and student or trainee year heterogeneity, we recruited self-identifying Black medical students and surgical residents across Canada. Online in-depth semistructured interviews were conducted and transcribed verbatim. Transcripts were analyzed through an inductive reflexive narrative thematic process by 4 analysts.

RESULTS

Twenty-seven participants including 18 medical students and 9 residents, were interviewed. The results showed 3 major themes that characterized their experiences: journey to and through medicine, perceptions of the surgical culture, and recommendations to improve the student experience. Medical students identified lack of mentorship and representation as well as experiences with racism as the main barriers to pursuing surgical training. Surgical trainees cited systemic racism, lack of representation, and insufficient safe spaces as the key deterrents to program completion. The intersection with sex exponentially increased these identified barriers.

CONCLUSIONS

Except for a few surgical programs, medical schools across Canada do not offer a safe space for Black students and trainees to access and complete surgical training. An urgent change is needed to provide diverse mentorship that is transparent, acknowledges the real challenges related to systemic racism and biases, and is inclusive of different racial and ethnic backgrounds.

The Perspective of Brazilian Women Orthopaedic Surgeons on Gender Discrimination: Initial Insights to Understand Gender Bias in the Brazilian Healthcare System

Despite the societal progress made in recent years, gender discrimination is still common in healthcare, especially in some surgical specialties such as orthopaedics. In Brazil, where the participation of women in the medical profession has been increasing, little is known about women's perceptions on the issue of gender discrimination. This study aims to examine women orthopaedic surgeons' experiences in dealing with conflict in the workplace and contextualize the impact that gender discrimination has had or currently has on their careers and well-being. As a secondary objective, the work seeks to understand whether there are differences in the perception of the issue among practicing women orthopaedic surgeons and those in training. For a cross-sectional qualitative study, a survey was distributed exclusively to 300 practicing orthopaedic surgeons and orthopaedists in training (residents and fellows). A total of 99 women participated in the survey, of whom 66 were practicing orthopaedic surgeons and 33 were orthopaedists in training. The study showed that women orthopaedic surgeons in training in Brazil have a lower number of publications and a moderate level of involvement in academic society activity. In addition, orthopaedic surgeons in training experience a statistically significantly higher number of conflicts in the workplace. The comments from the questionnaires highlighted the physical and psychological consequences arising from these situations of professional conflict, most frequently occurring with orthopaedic surgeons who are men. Our findings indicate that respondents expressed a feeling of inequality towards women in the workplace, ultimately reducing the level of job satisfaction among female orthopaedic surgeons, which may contribute to disinterest and abandonment of the specialty. The results of this work support recent evidence that there is an implicit and often overlooked bias against the participation of women and ethnic minorities in the orthopaedic community in Brazil.

UK pregnancy in orthopaedics (UK-POP): a cross-sectional study of UK female trauma and orthopaedic surgeons and their experiences of pregnancy

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

Methods

This is a cross-sectional study using an anonymous 13-section web-based survey distributed to female-identifying T&O trainees, speciality and associate specialist surgeons (SASs) and locally employed doctors (LEDs), fellows, and consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out.

Results

A total of 226 UK female T&O surgeons completed the survey. All regions of the UK were represented. Overall, 99/226 (44%) of respondents had at least one child, while 21/226 (9.3%) did not want children. Median age at first child was 33 years (interquartile range 32 to 36). Two-thirds (149/226; 66%) of respondents delayed childbearing due to a career in T&O and 140/226 (69%) of respondents had experienced bias from colleagues directed at female T&O surgeons having children during training. Nearly 24/121 (20%) of respondents required fertility assistance, 35/121 (28.9%) had experienced a miscarriage, and 53/121 (43.8%) had experienced obstetric complications.

Conclusion

A large proportion of female T&O surgeons have and want children. T&O surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female T&O surgeons with decision making and assist employers with workforce planning. Further steps are necessary in order to support female T&O surgeons having families.

The Importance of Perceived Barriers to Women Entering and Advancing in Orthopaedic Surgery in the US and Beyond

BACKGROUND

Global perceptions of barriers to women in orthopaedics have not been assessed. The purpose of this study was to determine the importance of international barriers to women entering and advancing within orthopaedic surgery.

METHODS

An anonymous, online survey was distributed to women medical students, trainees, and practicing surgeons via Women in Orthopaedics Worldwide, the "Women in Ortho" Facebook page, and individual programmes. Participants were asked to rate perceived barriers to (1) pursuing training and (2) career advancement on a scale of 1-5, with 5 being the most important and relative to other barriers. Descriptive statistics and univariate analyses were employed.

RESULTS

The survey yielded 237 US (84.0%) and 45 international (16.0%) respondents. Per entering orthopaedic surgery, the most important barriers were male-dominated culture, lack of a strong women mentor, and lack of female representation at home institution. Compared with the US surgeons/trainees, international respondents cited greater societal disapproval (2.8 ± 1.2 vs. 3.4 ± 1.3, P = 0.01). Medical students assigned less importance to lack of exposure, more to lack of resources for creating competitive applications (P < 0.05). Regarding career advancement, lack of women leadership, family responsibilities, and gender-biased selection for promotion were the most important. International surgeons/trainees noted greater concern for societal disapproval (3.5 ± 1.5 vs. 2.6 ± 1.3, P = 0.003) and were more likely to rank sexual harassment in their top three (17.6 vs. 4.2%, P = 0.02).

CONCLUSION

While notable differences exist, there is striking similarity across countries and position levels in perceived barriers to women entering and advancing in orthopaedic surgery.

LEVEL OF EVIDENCE

III.