The importance of diversity, equity, and inclusion in orthopedic research

Let's Take a Look at the Tape: The Impact of ERAS Video Prompts on Interview Offerings for Orthopaedic Surgery Residency Applicants: A Prospective Observational Study

INTRODUCTION

Matching into an orthopaedic surgery residency consistently reinforces a competitive landscape, challenging the applicants and programs. A group of orthopaedic surgery residency programs implemented video prompts asking applicants to respond to a standardized question by video recording. Assessing the impact of this video on the decision to offer an interview can help guide programs and applicants through the interview process.

METHODS

Twenty residency applications to one institution requiring video prompts were randomly selected and deidentified. Thirteen experienced faculty from various orthopaedic surgery programs served as applicant reviewers. The reviewers evaluated the electronic residency application service (ERAS) application and determined whether they would grant the applicant an interview ("no," "maybe," or "yes") before and after watching the video prompt. The reviewer also scored the impact of the applicant's dress, facial presentation, and video background distractions on their evaluation of the video. Multivariable logistic regressions were conducted using a group of applicants where interview status was not impacted by the video compared with the group of applicants where the interview status changed after video review. An alpha value of 0.05 was used to define significance.

RESULTS

The video prompt impacted the decision to offer an interview 29.3% of the time; 15.8% were switched from "yes" or "maybe" to "no" and 13.5% were switched from "no" or "maybe" to "yes." For the positively impacted applicants, facial presentation score was significantly higher ( P = 0.005). No recorded variables were associated with decreased chance of interview.

DISCUSSION

Video prompts impacted the decision to offer interviews to orthopaedic surgery applicants approximately one-third of the time, with a similar number of applicants being positively and negatively impacted. Facial presentation score was associated with increased chance of interview, and no variables were associated with decreased chance of interview. Thus, the answer to the videos presumably negatively impacted applicants.

Learning on a Limb: An outreach module to engage high school students in orthopaedics

Orthopaedic researchers need new strategies for engaging underrepresented minority (URM) students. Our field has demonstrated noticeable gaps in racial, ethnic, and gender diversity, which inhibit our ability to innovate and combat the severe socioeconomic burden of musculoskeletal disorders. Towards this goal, we designed, implemented, and evaluated Learning on a Limb (LoaL), an orthopaedic research outreach module to teach URM high school students about orthopaedic research. During the 4-h module, students completed hands-on activities to learn how biomechanical testing, microcomputed tomography, cell culture, and histology are used in orthopaedic research. Over 3 years, we recruited 32 high school students from the Greater Philadelphia Area to participate in LoaL. Most participants identified as racial/ethnic or gender minorities in orthopaedic research. Using pre/post-tests, we found that students experienced significant learning gains of 51 percentage points from completing LoaL. In addition to teaching students about orthopaedic research, post-survey data demonstrated that participating in LoaL strongly influenced students' interest in orthopaedic research and scientific confidence. Several students acted on this interest by completing summer research experiences in the McKay Orthopaedic Research Laboratory at the University of Pennsylvania. LoaL instructors also benefited by having the opportunity to "pay it forward" to the next generation of students and build community within their department. Empowering institutions to host modules like LoaL would synergistically inspire URM high school students and strengthen community within orthopaedic departments to ultimately enhance orthopaedic research innovations.

Becoming JEDI Warriors in Physical Therapy Research: A Multifaceted Approach

The COVID-19 pandemic and recent incidents of social injustice exposed the systemic racism and discrimination in health care and clinical research that perpetuate systemic inequities. This perspective utilizes the acronym JEDI (justice, equity, diversity, and inclusion) as a vision for addressing inequities in physical therapy research. The need to go beyond diversity and focus on inclusion, equity, and justice is emphasized to achieve transformation within physical therapy research. The prevailing research paradigms are examined, acknowledging that research can perpetuate inequities and reinforcing the importance of integrating JEDI principles into the research process. The underrepresentation of diverse researchers in physical therapy is discussed, as well as the barriers faced by underrepresented researchers and research participants. Funding disparities are also highlighted, emphasizing the need for JEDI principles in research funding practices. How other health professions' associations are addressing JEDI in research is also explored. The authors propose a framework for action, utilizing the concepts of the socioecological model to identify gaps in JEDI within physical therapy research at different levels of influence and conclude by emphasizing the importance of justice in dismantling inequitable systems and urge the physical therapy research community to become JEDI warriors to bring about transformative change.

IMPACT

By championing cultures that value justice, equity, diversity, and inclusion, individuals within the physical therapy research community have the potential to ignite a powerful transformation in society. The authors envision a future where JEDI warriors emerge, embracing the spirit of "Do or do not. There is no try," to forge a research community that is inclusive for all. 1 Drawing inspiration from this mindset, this perspective seeks to empower individuals to harness the force of a JEDI warrior, fostering cultures that value justice, embrace inclusive methodologies, and ensure equitable access to resources and opportunities for researchers and participants.

Learning on a Limb: An outreach module to engage high school students in orthopaedics

Orthopaedic researchers need new strategies for engaging diverse students. Our field has demonstrated noticeable gaps in racial, ethnic, and gender diversity, which inhibit our ability to innovate and combat the severe socioeconomic burden of musculoskeletal disorders. Towards this goal, we designed, implemented, and evaluated Learning on a Limb, an orthopaedic research outreach module to teach diverse high school students about orthopaedic research. During the 4-hr module, students completed hands-on activities to learn how biomechanical testing, microcomputed tomography, cell culture, and histology are used in orthopaedic research. Over three years, we recruited 32 high school students from the Greater Philadelphia Area to participate in Learning on a Limb. Most participants identified as racial/ethnic or gender minorities in orthopaedic research. Using pre/post-tests, we found that students experienced significant learning gains of 51 percentage points from completing Learning on a Limb. In addition to teaching students about orthopaedic research, post-survey data demonstrated that participating in Learning on a Limb strongly influenced students' interest in orthopaedic research. Several students acted on this interest by completing summer research experiences in the McKay Orthopaedic Research Laboratory at the University of Pennsylvania. Learning on a Limb instructors also benefited by having the opportunity to "pay it forward" to the next generation of students and build community within their department. Empowering institutions to host modules like Learning on a Limb would synergistically inspire diverse high school students and strengthen community within orthopaedic departments to ultimately enhance orthopaedic research innovations.

Racial and Ethnic Minorities Underrepresented in Pain Management Guidelines for Total Joint Arthroplasty: A Meta-analysis

BACKGROUND

Total joint arthroplasty aims to improve quality of life and functional outcomes for all patients, primarily by reducing their pain. This goal requires clinical practice guidelines (CPGs) that equitably represent and enroll patients from all racial/ethnic groups. To our knowledge, there has been no formal evaluation of the racial/ethnic composition of the patient population in the studies that informed the leading CPGs on the topic of pain management after arthroplasty surgery.

QUESTIONS/PURPOSES

Using papers included in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines and comparing them with US National census data, we asked: (1) What is the representation of racial/ethnic groups in randomized controlled trials compared with their representation in the US national population? (2) Is there a relationship between the reporting of racial/ethnic groups and year of data collection/publication, location of study, funding source, or guideline section?

METHODS

Participant demographic data (study year published, study type, guideline section, year of data collection, study site, study funding, study size, gender, age, and race/ethnicity) were collected from articles cited by this guideline. Studies were included if they were full text, were primary research articles conducted primarily within the United States, and if they reported racial and ethnic characteristics of the participants. The exclusion criteria included duplicate articles, articles that included the same participant population (only the latest dated article was included), and the following article types: systematic reviews, nonsystematic reviews, terminology reports, professional guidelines, expert opinions, population-based studies, surgical trials, retrospective cohort observational studies, prospective cohort observational studies, cost-effectiveness studies, and meta-analyses. Eighty-two percent (223 of 271) of articles met inclusion criteria. Our original literature search yielded 27 papers reporting the race/ethnicity of participants, including 24 US-based studies and three studies conducted in other countries; only US-based studies were utilized as the focus of this study. We defined race/ethnicity reporting as the listing of participants' race or ethnicity in the body, tables, figures, or supplemental data of a study. National census information from 2000 to 2019 was then used to generate a representation quotient (RQ), which compared the representation of racial/ethnic groups within study populations to their respective demographic representation in the national population. An RQ value greater than 1 indicates an overrepresented group and an RQ value less than 1 indicates an underrepresented group, relative to the US population. Primary outcome measures of RQ value versus time of publication for each racial/ethnic group were evaluated with linear regression analysis, and race reporting and manuscript parameters were analyzed with chi-square analyses.

RESULTS

Two US-based studies reported race and ethnicity independently. Among the 24 US-based studies reporting race/ethnicity, the overall RQ was 0.70 for Black participants, 0.09 for Hispanic participants, 0.1 for American Indian/Alaska Natives, 0 for Native Hawaiian/Pacific Islanders, 0.08 for Asian participants, and 1.37 for White participants, meaning White participants were overrepresented by 37%, Black participants were underrepresented by 30%, Hispanic participants were underrepresented by 91%, Asian participants were underrepresented by 92%, American Indian/Alaska Natives were 90% underrepresented, and Native Hawaiian Pacific Islanders were virtually not represented compared with the US national population. On chi-square analysis, there were differences between race/ethnicity reporting among studies with academic, industry, and dual-supported funding sources (χ 2 = 7.449; p = 0.02). Differences were also found between race/ethnicity reporting among US-based and non-US-based studies (χ 2 = 36.506; p < 0.001), with 93% (25 of 27) of US-based studies reporting race as opposed to only 7% (2 of 27) of non-US-based studies. Finally, there was no relationship between race/ethnicity reporting and the year of data collection or guideline section referenced.

CONCLUSION

The 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines provide evidence-based recommendations that reflect the current standards in orthopaedic surgery, but the studies upon which they are based overwhelmingly underenroll and underreport racial/ethnic minorities relative to their proportions in the US population. As these factors impact analgesic administration, their continued neglect may perpetuate inequities in outcomes after TJA.

CLINICAL RELEVANCE

Our study demonstrates that all non-White racial/ethnic groups were underrepresented relative to their proportion of the US population in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines, underscoring a weakness in the orthopaedic surgery evidence base and questioning the overall external validity and generalizability of these combined CPGs. An effort should be made to equitably enroll and report outcomes for all racial/ethnic groups in any updated CPGs.

Are our actions matching our words? A review of trainee ethnic and gender diversity in orthopaedic surgery

Background

There is a lack of physician ethnic and gender diversity amongst surgical specialties. This study analyzes the literature that promotes diversity amongst surgical trainees. Specifically, this study sought to answer (i) how the number of publications regarding diversity in orthopaedic surgery compares to other surgical specialties, (ii) how the number of publications amongst all surgical subspecialties trends over time and (iii) which specific topics regarding diversity are discussed in the surgical literature.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to query articles from PubMed, Web of Science, Embase and the Cumulative Index to Nursing and Allied Health Literature. Broad inclusion criteria for both ethnic and gender diversity of any surgical specialty were utilized.

Results

Our query resulted 1429 publications, of which 408 duplicates were removed, and 701 were excluded on title and abstract screening, leaving 320 to be included. The highest number of related publications was in orthopaedic surgery (n = 73) followed by general surgery (n = 56). Out of 320 total articles, 260 (81.3 %) were published after 2015, and 56 of 73 (76.7 %) orthopaedic-specific articles were published after 2015.

Conclusion

Orthopaedic surgery published the most about ethnic and gender diversity, however, still remains one of the least diverse surgical specialties. With the recent increase in publications on diversity in surgical training, close attention should be paid to ethnic and gender diversity amongst surgical trainees over the coming years. Should diversity remain stagnant, diversification efforts may need to be restructured to achieve a diverse surgeon workforce.

Key message

Orthopaedic surgery is the surgical subspecialty that publishes the most about trainee ethnic and gender diversity followed by general surgery. With most of this literature being published over the last eight years, it is imperative to pay close attention to the ethnic and gender landscape of the surgeon workforce over the coming years.

Is There an Implicit Racial Bias in the Case Order of Elective Total Joint Arthroplasty?

INTRODUCTION

Identifying ways to improve equitable access to healthcare is of the utmost important. In this study, we analyzed whether patient race was negatively associated with surgical start times for total joint arthroplasties (TJA).

METHODS

The surgical case order and start times of all primary TJAs performed at a large academic medical center between May 2014 and May 2018 were retrospectively reviewed. Patients were included if > 21, had a documented self-reported race, and were operated on by an arthroplasty fellowship-trained surgeon. Operations were categorized as first-start, early (7:00 AM-11:00 AM), mid-day (11:00 AM-3:00 PM), or late (after 3:00 PM). Multivariable logistic regression (MLR) was performed, and odds ratios (OR) were calculated.

RESULTS

This study identified 1663 TJAs-871 total knee (TKA) and 792 total hip arthroplasties (THA) who met inclusion criteria. Overall, there was no association between race and surgical start time. Upon sub-analysis by surgical type, this held true for TKA patients, but self-identifying Hispanic and non-Hispanic Black patients undergoing THA were more likely to have later surgical start times (ORs: 2.08 and 1.88; p < 0.05).

DISCUSSION

Although there was no association between race and overall TJA surgical start times, patients with marginalized racial and ethnic identities were more likely to undergo elective THA later in the surgical day. Surgeons should be aware of potential implicit bias when determining case order to potentially prevent adverse outcomes due to staff fatigue or lack of proper resources later in the day.

Post or perish? Social media strategies for disseminating orthopedic research

Social media usage, particularly Twitter, among scientists in academia has increased in recent years. However, Twitter's use in scholarly post-publication dissemination of orthopaedic research and musculoskeletal advocacy remains low. To enhance usage of Twitter among musculoskeletal researchers, this article reviews data supporting the professional benefits of using the platform to disseminate scholarly works. Next, we provide a linear workflow for Tweet curation, discuss the importance of data-driven decision making behind tweet curation and posting, and propose new guidelines for professional Twitter usage. Since this workflow may not eliminate all the identified barriers and new institutionalized shifts in policies regarding curation and consumption of social media on Twitter, we also briefly introduce and explore using other social media platforms. We hope this information will be persuasive and compelling to those in the orthopedic research field and be broadly applicable to others in related scientific fields who wish to disseminate findings and engage a public audience on social media. In addition, we encourage the Orthopedic Research Society (ORS) and Journal of Orthopedic Research (JOR) communities to take advantage of the many tools curated by the Wiley editorial office and the ORS social media committee to increase dissemination of their scholarly works online. Twitter and social media can assist in accomplishing our mission of creating a world without musculoskeletal limitations via the timely dissemination of orthopedic information. However, this can only be accomplished if the orthopedic research community has a unified and strong online presence actively engaged in orthopaedic research findings and news.

Trends in Racial, Ethnic, and Gender Diversity Among Hand Surgery Fellows From 2007 to 2021

PURPOSE

There is a paucity of research on the demographic trends of orthopedic and plastic hand surgery fellows. The purpose of this study was to ascertain the current state of racial and gender demographic trends in hand surgery fellowship from 2007 to 2021.

METHODS

We analyzed fellowship demographic data from the Accreditation Council for Graduate Medical Education public database from 2007-2008 through 2020-2021. The gender of hand surgery fellows was categorized as male, female, or not reported and their race/ethnicity as White, Non-Hispanic; Asian or Pacific Islander, Hispanic; Black, Non-Hispanic; American Indian or Alaskan Native; other; or unknown. We extracted the number of fellows per year for each category and calculated the percentage equivalents and average percentages. We performed the chi-square test for trend (Cochran-Armitage test) to identify any significant changes in the percentages of gender and race/ethnicity between 2007 and 2021.

RESULTS

There was a significant increase in the percentage of hand surgery fellows who are women (20.7% to 30.7%) and Asian or Pacific Islander (13.3% to 25.3%). There was no significant change in the percentage of Hispanic or Black, Non-Hispanic fellows.

CONCLUSIONS

Although there have been some increases, hand surgery fellows continue to be underrepresented by women and minorities, consistent with the demographic of orthopedic and plastic surgery residents. There have been increasing trends in the number of women and minorities in medical schools, which leaves room for improvement from the downstream prospective applicant pool.

CLINICAL RELEVANCE

The physician-patient relationship can potentially be strengthened by race and gender concordance; however, many minority and female hand surgery patients do not have physicians who are women or of the same ethnic background. Patient satisfaction, trust, and potential health outcomes may be improved with a physician workforce that reflects the diversity of their patients.

Diversity in Leadership at Musculoskeletal Oncology Fellowships in the United States

Musculoskeletal oncology fellowship directors (MOFDs) possess the unique ability to influence treatment paradigms in musculoskeletal oncology through teaching and research. Currently, the characteristics that define this important role including demographics, training characteristics, research activity, and grant funding are poorly defined. A list of musculoskeletal oncology fellowship programs was obtained from the American Association of Hip and Knee Surgeons and Musculoskeletal Oncology Fellowship Match. Bibliometric data including the h-index were abstracted from Scopus. Demographics, training, and federal grant characteristics were collected from academic websites. Comparisons were made using t-tests and data were presented as means ± SD. The average age at the appointment was 41±9 years and most were male (80%) and Caucasian (85%). Few had an additional graduate degree (10% MS, 5% PhD). The mean h-index was 23±15 resulting from 91±56 publications. There was a positive correlation between age and h-index (r=0.398, p=0.082). Four MOFDs (20%) had at least one National Institutes of Health research grant. Sex, race, additional graduate degree, and procurement of NIH funding were not associated with higher h-index values. Full professors had higher h-index values than assistant/associate professors (p=0.014). Women and racial minorities are underrepresented among leadership positions in musculoskeletal oncology fellowship programs. This study can help provide a benchmark for departments in orthopedic surgery and aspiring orthopedic surgeons for MOFD positions.

A Pilot Program: Remote Summer Program to Improve Opportunity and Mentorship Among Underrepresented Students Pursuing Orthopaedic Surgery

The purpose of this study was to evaluate the impact of an 8-week remote summer program in supporting underrepresented students interested in orthopaedic surgery.

METHODS

We received 115 applications, and a total of 17 students participated in the program (14.8%). Nine faculty mentors were matched with 1 or 2 students each. The program delivered a curriculum from June-August 2021 consisting of (1) weekly instructional courses on research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic topics, diversity in medicine, leadership, and work-life balance; and (3) a research experience paired with a faculty mentor and peer mentor. We surveyed students to measure skill progression, satisfaction, and overall program evaluation. Preprogram/postprogram evaluation, midprogram check-in, and student feedback surveys were collected.

RESULTS

Program participants represented a range of race and ethnic backgrounds, research experience levels, and various geographic locations across the United States. The cohort included a high rate of female (42%) and Black (35%) participants. On average, postprogram survey scores indicated that participants believed that the summer program improved their research skills (9.6 of 10), improved their orthopaedic interest (8.9 of 10), and improved mentorship and networking (9.1 of 10). For feedback surveys, 14 respondents of 15 total responses (93%) felt they were adequately matched to their faculty mentor. Twelve (80%) felt they had realistic deliverables for research projects within the 8-week program. Thirteen (87%) indicated they contributed to an abstract or manuscript as a coauthor.

CONCLUSION

Our findings indicate that students improved their research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. The long-term goal is to improve the accessibility and quality of mentorship for underrepresented students in order to foster an equitable pathway into the field of orthopaedic surgery.

Orthopaedic Society Leadership Diversity and Academic Participation: Where Do We Stand Now?

BACKGROUND

In the United States, female and minority representation in the field of orthopaedic surgery remains low, and there are few reports regarding orthopaedic society leadership composition, selection criteria, and academic participation. We aimed to determine the demographic composition of national orthopaedic societies and report the academic participation metrics of leadership.

METHODS

This was a mixed-methods study using surveys and publicly available data from national orthopaedic societies for the 2020 to 2021 year. Twenty-four orthopaedic society websites were queried for their transparency in leadership selection and demographic information, including sex, racial, and ethnic composition of overall society and board membership. Data were collected regarding the academic participation of board leadership.

RESULTS

In total, 19 (79%) of the 24 national orthopaedic societies publish survey data regarding sex and racial demographics. One society elected not to participate, and there was no response from 4 others. Sixteen (89%) of the societies collect sex-related data from their membership, and 19 (100%) report sex-related data for their board members. Five (28%) collect data regarding the race and ethnicity of their general membership, and 10 (53%) report data regarding the race and ethnicity of board members. The average membership was 89% male and 11% female, and the leadership boards were 86% male and 14% female. In the societies that reported on race and ethnicity, on average, 80% of the members were White and 85% of the board members were White. Few societies (13%) publicly list their presidential nominating criteria, and none list their criteria for nonpresidential-line positions. Female sex and ≤10 years in practice were significantly associated with lower Hirsch index (h-index) scores, but these differences dissipated beyond 10 years.

CONCLUSIONS

There is a lack of sex, racial, and ethnic diversity in orthopaedic society leadership. More robust recording of these data by societies can help track improvements in diversity among members and leaders. Academic participation may be one component of leadership selection, but other factors play an important role. Overall transparency of leadership selection criteria could be clarified among orthopaedic societies.

Ethnic and Sex Diversity in Academic Orthopaedic Surgery: A Cross-sectional Study

Introduction:

Although the diversity in orthopaedic residency programs has been studied, the diversity within academic orthopaedics has not.

Methods:

The board of specialty societies, five leading journals and the National Institutes of Health RePORTER tool, and three accreditation organizations were explored.

Results:

The board of directors comprised 220 (72%) Caucasians, 36 (12%) Asians, 4 (1%) Hispanic/Latinos, 29 (9%) African Americans, and 18 (6%) Other individuals; 250 (81%) were men, and 57 (19%) were women. The editorial boards comprised 288 (77%) Caucasians, 62 (16%) Asians, 14 (4%) Hispanic/Latinos, 8 (2%) African Americans, and 4 (1%) Other individuals; 341 (91%) were men, and 35 (9%) were women. The National Institutes of Health grant recipients comprised 117 (64%) Caucasians, 58 (32%) Asians, 4 (2%) Hispanic/Latinos, and 3 (2%) African Americans; 128 (70%) were men, and 54 (30%) were women. On average, Caucasians, Asians, Hispanic/Latinos, and African Americans received $776,543, $439,600, $420,182, and $494,049, respectively. On average, men and women received $759,426 and $419,518, respectively. The accreditation boards comprised 45 (82%) Caucasians, 6 (11%) Asians, and 4 (7%) African Americans; 45 (82%) were men, and 10 (18%) were women.

Conclusions:

Academic orthopaedic surgery does not resemble the United States. Residency, fellowship committees, and professional organization boards need to become aware of these disparities.