Can a Strategic Pipeline Initiative Increase the Number of Women and Underrepresented Minorities in Orthopaedic Surgery?

Microaggression Interactions Among Healthcare Professionals, Trainees and Students in the Clinical Environment: A Mixed-Studies Review

This review aims to comprehensively consolidate and synthesize the existing body of empirical research on the perceptions and experiences of healthcare professionals, trainees, and students concerning microaggression interactions within diverse clinical settings. The review protocol was registered with the international prospective register of systematic reviews (PROSPERO CRD42024546443). We employed the Joanna Briggs Institute's mixed-methods systematic review approach. Comprehensive electronic database searches were conducted across eight databases (Medline, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Social Science Database, and ProQuest Dissertation and Theses) from their respective inception dates up to October 1, 2023. The selection criteria included studies reporting instances of interprofessional or intra-professional microaggressions occurring in clinical environments among healthcare professionals, trainees, and students identifying as heterosexual and without disabilities. In total, 37 studies met the eligibility criteria and were included in our review. Our analysis revealed three primary themes: Racial Microaggressions in the Clinical Environment, Gender Microaggressions in the Clinical Environment, and Religious Microaggressions in the Clinical Environment. Research must delve deeply into these experiences to better understand their long-term consequences, while policy initiatives should be designed to establish equitable, inclusive, and respectful healthcare environments. Collaborative endeavors bridging research and policy are paramount to dismantling barriers and nurturing an inclusive healthcare landscape.

Remote Summer Research Program to Improve Opportunity and Mentorship for Underrepresented Students With Interest in Orthopaedic Surgery: 3-Year Experiences

INTRODUCTION

Medical students are challenged with a limited number of research opportunities to help prepare for an exceptionally competitive process for matching in an orthopaedic residency. The aim of this study was to assess the 3-year experience of our 8 to 10-week remote summer research program in support of underrepresented students with an interest in orthopaedic surgery.

METHODS

We received over 500 applications, and a total of 37 students (7.4%) participated in the program over the past 3 years. A total of 14 faculty mentors were matched with 1 or 2 students each. The research program delivered a curriculum including (1) research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic conditions, diversity in orthopaedics, leadership, and work-life balance; and (3) a minimum of 8 weeks of mentorship experience with an assigned faculty and a peer mentor. Students and faculty were surveyed to measure skill progression, research productivity, and program satisfaction.

RESULTS

Program participants represented a range of race/ethnic backgrounds and research experience levels. The cohort included a high rate of female (51%) and Black (35%) participants relative to representation of these groups in orthopaedic surgery. Postprogram surveys indicated that all participants improved their research skills, orthopaedic interest, and mentorship/networking skills. Most students (89%) stated that they were adequately matched to their faculty mentor. Most students (79%) indicated that they contributed to either manuscript or conference abstract as coauthors.

DISCUSSION

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

Assessing students' perception of gender as a barrier in Orthopedic residency matching: A pilot survey study

BACKGROUND

Gender disparity in orthopedic residency programs is evident. Limited research investigates if gender attitudes deter women from applying to orthopedic surgery residency programs.

METHODS

A questionnaire was distributed to a single medical school which explored medical students' perceptions regarding their gender's influence on matching into orthopedic surgery residency, alongside motivators and barriers for applying. Descriptive statistics and chi-square tests analyzed potential association and trends using SPSS computation with alpha set at 0.05.

RESULTS

202 medical students completed the questionnaire. Women respondents were found to be 10.6 times more likely to report their own gender as a barrier to matching to orthopedic surgery residency compared to men.

CONCLUSION

A significant proportion of women perceive their gender as a barrier to matching. Dismantling gender stereotypes may increase consideration of women medical students of orthopedic surgery as a career option.

Increasing Diversity in Orthopaedic Surgery Residency: A Case Report of One Program's Experience Using Pipeline Programs

Introduction

African American, Hispanic, Asian, and Pacific Islanders are groups who are underrepresented in medicine (URM groups). Similarly, although women comprise more than 50% of medical students in the United States, women comprise a smaller percentage of all orthopaedic surgery trainees. Therefore, underrepresented in orthopaedics (URiO) represents the URM groups and women. The purpose of this study is to examine the impact of specific steps to recruit a qualified, diverse trainee complement within a single academic orthopaedic surgery residency program between 2000 and 2023. We aim to explore changes in the representation of URiO during this period as well as explore the strategies and programs implemented by the department that may have impacted recruitment of a diverse complement of trainees.

Methods

Match lists from a large, academic, orthopaedic surgery residency between 2000 and 2023 were collected and reviewed for racial and gender data. Match lists were then divided into 6-year quantiles to identify any trends in the recruitment of URiO students. Self-reported racial and gender data from Electronic Residency Application Service applicant reports and the Accreditation Council for Graduate Medical Education (ACGME) data books between 2018 and 2022 were collected and reviewed. In addition, the department's strategies implemented during the study period with the goal of enhancing URiO exposure to orthopaedic surgery were also explored.

Results

The department implemented proactive strategies to increase exposure to orthopaedic surgery for URiO students. An increase in URiO representation was noted between 2000 and 2023 with Hispanic, Black/African American, and Native Hawaiian/Pacific Islander resident representation increasing by 5%, 11%, and 1%, respectively. In addition, women representation increased by 27% between 2000 and 2023. The overall attrition rate among URiO residents was 1% with only one resident not completing the program. Self-reported racial and gender data from ACGME data books demonstrated that Black/African American, Hispanic, and Native Hawaiian/Pacific Islander residents comprised 5%, 4%, and 0.04%, respectively, of orthopaedic surgery residents between 2018 and 2022.

Conclusions

These results provide insight for other programs to use similar strategies to potentially improve recruitment, retain, and provide support to URiO residents.

Sex diversity in spine surgery fellowship training: analysis of recent trends and program characteristics associated with increased diversity

BACKGROUND CONTEXT

Sex diversity in the spine surgery workforce remains limited. Accelerated efforts to recruit more female trainees into spine surgery fellowship training may help promote diversity and inclusion in the emerging spine surgery workforce.

PURPOSE

This study assessed the representation of female trainees in spine surgery fellowship training and program factors associated with greater sex diversity among fellows.

STUDY DESIGN/SETTING

This was a cross-sectional analysis of spine surgery fellows in the United States during the 2016-2017 to 2022-2023 academic years.

PATIENT SAMPLE

N/A.

OUTCOME MEASURES

Representation (%) and participation-to-prevalence ratios (PPRs) defined as the participation of female trainees in spine surgery fellowship training divided by the prevalence of female trainees in previous training cohorts. PPR values <0.8 indicated underrepresentation.

METHODS

Sex diversity was assessed among spine surgery faculty, spine surgery fellows, orthopaedic surgery residents, neurosurgery residents, and allopathic medical students. Fellowship program characteristics associated with increased sex diversity were calculated with chi square tests.

RESULTS

There were 693 spine surgery fellows and 41 were female (5.9%). Sex diversity in spine surgery fellowship training decreased over the study period (6.4% vs. 4.1%, p=.025). Female trainee representation in spine surgery fellowship training was less than that in orthopaedic surgery residency (14.2%, PPR=0.42), neurosurgery residency (17.1%, PPR=0.35), and allopathic medical school (47.6%, PPR=0.12) training (p<.001). There were 508 faculty at 78 spine surgery fellowships and 25 were female (4.9%). There were 3 female fellowship program directors (3.8%). Fellowship program characteristics associated with increased sex diversity included the presence of female faculty (p=.020). Additional program characteristics including geographic region, accreditation status, number of faculty and fellows were not associated with sex diversity (p>.05).

CONCLUSIONS

Female representation in spine surgery fellowship training decreased over the study period and remains underrepresented relative to earlier stages of medical and surgical training. There was a positive association between female faculty and increased sex diversity among fellows. Greater efforts are needed to create training environments that promote diversity, equity, and inclusion in spine surgery fellowship training.

AOA Critical Issues Symposium: Advancing Diversity, Equity, and Inclusion in Orthopaedic Surgery

ABSTRACT

In recent years, the medical field has recognized the pivotal role of diversity, equity, and inclusion (DEI) in enhancing patient care and addressing health-care disparities. Orthopaedic surgery has embraced these principles to create a more inclusive and representative workforce. A DEI symposium that was sponsored by the American Orthopaedic Association convened orthopaedic surgeons, researchers, educators, and stakeholders to discuss challenges and strategies for implementing DEI initiatives. The symposium emphasized the importance of equity, and fostered conversations on creating equal opportunities and resources. Speakers covered key topics, including establishing DEI divisions, metrics for success, DEI leadership, and available resources, and promoted excellence and innovation in orthopaedic surgery through a more diverse and inclusive approach.

The gender role in the publishing of Authorships in high-impact orthopedic journals

To evidence the existence of a gender gap in the orthopedic scientific literature by including also differences between some specific orthopedic surgery specialities, such as hands and feet. Then, we also considered gender role in the Authorship linked with the economic wealth of each country belonging to each Author. The gender of the first Authors of journals on orthopedics and sports medicine indexing in the Scopus database with the highest impact factor (IF) related to the year 2019, for the period from January 1, 2015, to December 31, 2020, were considered. A total of 11 journals were considered, including a total of 5474 articles, 1087 (19.86%) had a woman as the first Author and 4387 (80.14%) a man. During the studied period, the trend seems to be the same (p = 0.906): Men were significantly more producing than women in the orthopedic field both by considering the topic of the journal (p = .003), all the most impacted orthopedic journals (p < 0.001) and economies (p < 0.001). There was therefore a strong significance: In the orthopedic field, there were significantly more male researchers who presented their first name in scientific publications compared to females in all orthopedic subspecialties. The economically poorer countries published less and the role of women became almost absent.

Bridging the Gap: Advocating for Medical Students Without Home Orthopaedic Surgery Programs

Medical students without a home orthopaedic surgery program face unique challenges due to the absence of institutional connections and mentorship opportunities. This review explores the hurdles faced by these students, including financial constraints, emotional strains, mentorship gaps, and networking hurdles. Drawing from empirical evidence and scholarly research, tailored advocacy strategies to empower these medical students pursuing orthopaedic surgery residency are proposed, including mentorship programs, financial assistance, psychosocial support, and community-building initiatives.

Gender diversity in the National Joint Registry

Aims

Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.

Methods

Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration.

Results

Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001).

Conclusion

Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons.

Sex Diversity and Equity Among Fellows of the American Orthopaedic Association

BACKGROUND

We hypothesized that women are underrepresented among fellows of the American Orthopaedic Association (AOA) relative to their prevalence among faculty at departments of orthopaedic surgery.

METHODS

Clinical faculty at departments of orthopaedic surgery that are affiliated with residency training programs were analyzed for AOA membership. Participation-to-prevalence ratios (PPRs) were calculated for men and women with AOA membership relative to their prevalence among orthopaedic surgeon faculty. A PPR of <0.8 or >1.2 indicated under- or overrepresentation, respectively. PPR values between 0.8 and 1.2 indicated equivalent representation. Sex disparities in AOA membership were explored by academic rank and orthopaedic subspecialty.

RESULTS

There were 4,310 orthopaedic surgery faculty, and 998 (23.2%) had AOA membership. Overall, women formed the minority of members in the AOA study cohort (11.4%), but they had equivalent representation relative to their prevalence among faculty (10.0%, PPR = 1.14, p = 0.210). In the AOA study cohort, women were the minority at each academic rank, including assistant professor (20.2% versus 79.8%, p < 0.001), associate professor (16.8% versus 83.2%, p < 0.001), and full professor (7.0% versus 93.0%, p < 0.001). However, women had greater representation in the AOA study cohort at each academic rank than would be expected based on their prevalence among faculty, including the assistant (PPR = 1.45), associate (PPR = 1.56), and full (PPR = 1.27) professor levels. Similarly, in the AOA study cohort, women were the minority in each orthopaedic subspecialty, but were only underrepresented in pediatric orthopaedics (PPR = 0.74). Women had greater representation in the AOA study cohort than would be expected by their prevalence among faculty in hand surgery (PPR = 1.51) and orthopaedic sports medicine (PPR = 1.33). In contrast, men had equivalent representation in each orthopaedic subspecialty.

CONCLUSIONS

Women form a minority group in the AOA, but they exhibit greater representation in the AOA than would be expected based on their prevalence among faculty at each academic rank, and they have greater representation than men, who exhibit equivalent representation across all academic ranks. Collectively, these results disproved our hypothesis, and suggest that women are participating in the AOA at rates that are greater than their prevalence among faculty.

CLINICAL RELEVANCE

Equitable participation of women in orthopaedic surgery is necessary to promote diversity and inclusion in the specialty. The AOA may be an important catalyst for future positive diversity and inclusion efforts within orthopaedic surgery.

Advancing diversity in spine surgery: the critical role of professional societies and foundations

This manuscript examines the challenges and initiatives within organizations associated with spine surgery to enhance diversity, equity, and inclusion (DEI), focusing on the systemic barriers that hinder the representation of women and underrepresented in medicine (URiM) minorities. Highlighting the contributions of pioneering individuals who overcame racial and gender discrimination to forge paths in these fields, it stresses the importance of professional societies and foundations in promoting DEI. Despite advancements, legal challenges and recent legislation in various states threaten to undermine DEI efforts, presenting a critical moment for organizations to reassess and reinforce their strategies. By detailing the roles of specific professional societies, foundations, and initiatives like the American Society of Black Neurosurgeons and Nth Dimensions, the manuscript underscores the necessity of targeted actions to ensure the progress toward a more inclusive and equitable spine surgery community.

What is the impact of DEI on spine care? Does it matter if my doctor looks like me?

Though the United States population has rapidly diversified in recent decades, the American physician workforce has been slow to follow. Orthopedic surgery and neurosurgery are 2 specialties which remain particularly homogenous, and the subset of orthopedic surgeons and neurosurgeons who pursue spine surgery is even less diverse, along many different demographic axes. To provide effective, innovative, and accessible care to the changing population, greater diversity in spine surgery is essential. This is achieved in part by recruitment, retention, and leadership sponsorship of a new generation of trainees and faculty who reflect the diversity of the patient population they will care for. For surgeons, workforce diversity means improved learning, innovation, and organizational performance. For patients, it means greater ability to access respectful, quality care. Investing in the future of spine surgery means creating a more diverse and inclusive field, 1 in which patients from all walks of life can say, "My doctor is different-like me."

You say you want to be "diverse": what are the practical steps towards increasing diversity of spine surgeons?

This article explores the critical issue of underrepresentation in spine surgery, specifically addressing racial/ethnic diversity. The paper proposes actionable strategies to enhance diversity within spine surgery through early education and outreach, intentional mentorship and sponsorship, and addressing biases in recruitment and promotion processes. It emphasizes the importance of a supportive culture within spine surgery divisions and practices, advocating for a top-down approach to inclusivity, while underscoring the necessity of continuous evaluation and adaptation of diversity initiatives. By leveraging diverse perspectives, the field of spine surgery can better serve an increasingly heterogeneous population, ultimately improving patient care and healthcare outcomes.

Science, Medicine, and Cytology: an educational program of the Diversity, Equity, and Inclusion Committee of the American Society of Cytopathology

INTRODUCTION

As our field of pathology continues to grow, our trainee numbers are on the decline. To combat this trend, the ASC Diversity, Equity, and Inclusion Committee established the Science, Medicine, and Cytology SumMer Certificate program to improve exposure to pathology/cytopathology with a focus on diversity, equity, and inclusion. Herein, we report our findings of the first 2 years of the program.

MATERIALS AND METHODS

An online course was developed targeting students who are underrepresented in medicine at the high school and college level. It consisted of several didactic sessions, presenting the common procedures involving cytopathologists and cytologists. Interviews with cytopathologists were also included. Participants were surveyed for demographic information and provided course evaluations.

RESULTS

In the first year of the program (2021), 34 participants completed the program, which increased to 103 in 2022. In both years there was a diversity in participant demographic backgrounds; however, only a minority of participants self-identified as being underrepresented in medicine. A vast majority (>85%) of participants in both years were high school or college students. In 2021, 100% of participants stated that the program format was effective and 94% thought the content was appropriate for their level of education; in 2022 the results were similar. In 2021, 66% considered health care as a potential career; this value increased in 2022 to 83%. In 2021 and 2022, 31% and 38%, respectively, considered cytology as a career.

CONCLUSIONS

Evaluations were excellent, generating interest in cytopathology. Barriers in reaching underrepresented minorities exist and additional work is needed. Expansion to a wider audience may increase outreach.

How long will it take to reach the gender diversity goal for orthopaedics in Japan?

BACKGROUND

In Japan, orthopaedics is one of the medical fields with the lowest proportion of women. This study analyses the change in gender diversity over the past decade and estimates the time required to achieve the 30% gender diversity goal, according to the critical mass in Japan in 2020.

METHODS

We investigated the demographic composition of orthopaedic surgeons in 2020 by age group, the gender ratio of the main clinical fields from 2010 to 2020, and estimated the time required for the bottom 10 (i.e., least diverse) medical departments in Japan to reach the proportion of 30% women. We used simple linear regression analyses to clarify the number of years.

RESULTS

In 2020, the population pyramid of orthopaedic surgeons showed that those in their 50s were the largest component with 24.1%, followed by those in their 40s and 30s with 22.3% and 19.4%, respectively. The percentage of women orthopaedic surgeons increased slightly from 4.1% in 2010 to 5.7% in 2020. This means that to achieve the proportion of 30% women at the current annual increase rate, orthopaedics would require up to 160 years, cardiovascular 149 years, and neurosurgery 135 years.

CONCLUSION

Contrary to the recent increase in the number of women physicians, there has been only a slight increase in the number of women orthopaedic surgeons over the past decade. Moreover, the number of young male orthopaedic surgeons has decreased. As current orthopaedic surgeons age and retire, Japan will soon face an overall shortage of orthopaedic surgeons. Issues that must still be addressed in Japanese orthopaedics include educating men and women about gender diversity and bias, changing stereotypes about surgical lifestyles, improving work-life balance, and diligent and collaborative efforts at both the individual and community levels.

Diversity of Backgrounds and Academic Accomplishments for Presidents Elected to Hip and Knee Arthroplasty Societies in the United States

BACKGROUND

Academic accomplishments and demographics for presidents of hip and knee arthroplasty societies are poorly understood. This study compares the characteristics of presidents nominated to serve the Hip Society, Knee Society, and American Association of Hip and Knee Surgeons.

METHODS

This was a cross-sectional study of arthroplasty presidents in the United States (1990 to 2022). Curriculum vitae and academic websites were analyzed for demographic, training, bibliometric, and National Institutes of Health (NIH) funding data. Comparisons were made between organizations and time periods (1990 to 2005 versus 2006 to 2022).

RESULTS

There were 97 appointments of 78 unique arthroplasty presidents (80%). Most presidents were male (99%) and Caucasian (95%). There was 1 woman (1%) and 5 non-Caucasian presidents (2% Asian, 3% Hispanic). There were no differences in demographics between the 3 arthroplasty organizations and the 2 time periods (P > .05). Presidents were appointed at 55 ± 10 years old, which was on average 24 years after completion of residency training. Most presidents had arthroplasty fellowship training (68%), and the most common were the Hospital for Special Surgery (21%) and Massachusetts General Hospital (8%). The median h-index was 53 resulting from 191 peer-reviewed publications, which was similar between the 3 organizations (P > .05). There were 2 presidents who had NIH funding (2%), and there were no differences in NIH funding between the 3 organizations (P > .05).

CONCLUSIONS

Arthroplasty society presidents have diverse training pedigrees, high levels of scholarly output, and similar demographics. There may be future opportunities to promote diversity and inclusion among the highest levels of leadership in total joint arthroplasty.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

BACKGROUND

Orthopaedic surgery has a diversity gap, as it is not representative of the racial or sex proportions of the U.S. population. This gap can lead to communication barriers stemming from health literacy, language proficiency, or cultural discordance that may contribute to current health inequities. This study assesses the influence of educational attainment, language, and cultural concordance on patient-physician communication.

METHODS

In this cross-sectional study, 394 patients from an urban orthopaedic clinic were administered a Likert-type survey regarding race or ethnicity, educational level, communication, patient satisfaction, language proficiency, and culture. One-way analysis of variance, chi-square tests, and Welch t tests were used to evaluate responses.

RESULTS

The majority of subjects identified as African-American/Black (50%) or Hispanic/Latino (30%). Completing high school was associated with a better ability of the subjects to communicate with their orthopaedic surgeon (p < 0.001). Hispanic subjects reported lower English proficiency (p < 0.001) and decreased ability to communicate with their physician (p < 0.001) compared with other subjects, with educational attainment influencing their ability to understand their orthopaedic surgeon in English (p < 0.001). African-American and Hispanic patients placed greater importance on orthopaedic surgeons understanding their culture than White patients (p < 0.001). Hispanic patients who saw a language and culture-concordant surgeon valued having a Spanish-speaking surgeon more than Hispanic patients who did not see a concordant surgeon (p = 0.04).

CONCLUSIONS

These results suggest that patient-physician language concordance, particularly in patients with lower education, may be essential to delivering high-quality patient care. Hispanic and African-American patients placed significantly greater importance on their orthopaedic surgeons understanding their culture. Hispanic patients frequently sought care with language-concordant surgeons and placed higher value on physicians understanding their culture. To better serve minority communities, efforts should be made to increase orthopaedic surgeons' cultural humility and to recruit a diverse multilingual surgeon workforce.

CLINICAL RELEVANCE

This research demonstrates that cultural and language concordance, specifically between Hispanic patients and Hispanic, Spanish-speaking surgeons, can significantly enhance patient preference and potentially improve patient satisfaction and outcomes in orthopaedic care. Additionally, it underscores the importance of understanding and addressing the diversity within the field and the patient population to better meet the needs of a multicultural society.

Reaching back to enhance the future: the American Association for the Surgery of Trauma Diversity, Equity and Inclusion Pipeline Program

Objectives

There are significant disparities in the surgical workforce in comparison with medical student demographics. Pipeline programs have shown to be effective in addressing gaps. The American Association for the Surgery of Trauma Diversity, Equity and Inclusion Committee designed a longitudinal pipeline program with high school student mentees and surgeon mentors providing an in-person hands-on workshop.

Methods

The mentee demographics and socioeconomic status at the time of application were determined using overall percentages and the Area Deprivation Index (ADI). Program application essays were qualitatively analyzed for common themes. The pre-workshop and post-workshop and 6-month follow-up surveys were analyzed for mentee experience and areas for improvement.

Results

Mentees selected were 30% male (N=3 of 10), 70% female (N=7 of 10), 50% black or African American (N=5 of 10) and 30% Hispanic or Latinx (N=3 of 10). The majority of mentees were in the most disadvantaged groups in their state by the ADI (N=8 of 9, 89%). Many of the application essays highlighted a personal loss as driving the interest in a health career with several of those losses based on 'gun violence'. There was under-representation in medicine racial/ethnic or gender concordance for 80% (N=8 of 10) of the mentee-mentor pairings. In the pre-workshop survey, even those students with high-grade point averages and strong academic achievement in science courses indicated low confidence in their ability to succeed. Most students (N=7 of 10, 70%) reported a strong positive connection with their mentor in the post-workshop survey. There was a reduction in self-identified modifiable barriers to success for 83% (N=5 of 6) of the mentees. One-third of students who responded to the 6-month survey indicated that they had issues with maintaining contact with their mentors after the workshop.

Conclusion

The pipeline program was able to reach the target demographic and increase interest in surgery. Positive mentee/mentor relationships were formed. There are improvements to be made in longitudinal components of the program to ensure lasting results.

Level of evidence

III.

The American Association of Latino Orthopaedic Surgeons: Our History, Achievements, and Future Goals

ABSTRACT

The mission of the American Association of Latino Orthopaedic Surgeons (AALOS) is to provide collegiality, advancement, education, and social justice for Latino orthopaedic surgeons and the minority populations they represent. We strive to enhance diversity within the field of orthopaedic surgery by increasing the visibility of AALOS, highlighting its core focus, and emphasizing its mission. The purposes of this article are to discuss the need for this organization and highlight its history and future goals. As AALOS recently celebrated its 15-year anniversary, we are excited to continue advancing the field of orthopaedic surgery and improving our patients' care.

The Sex or Race of Program Directors May Not Play a Significant Role in Impacting Diversity Among Orthopaedic Surgery Residents

PURPOSE

To identify the influence of residency program characteristics, including the presence of under-represented minorities in medicine (URiM) and/or female program directors (PDs), on the race and sex distribution of orthopaedic surgery residency trainees.

METHODS

All active and Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs from 2017-2021 that reported usable information in the Residency Explorer Tool were included. Data collected included program characteristics, as well as faculty and resident sex distribution, ethnicity, race, and demographic characteristics. The PDs' specific sex, ethnicity, race, and demographic characteristics were collected using residency program websites. The prevalence of factors in programs with the top quartile of female and URiM residents was compared with that in programs with the bottom 3 quartiles.

RESULTS

Data were obtained from 148 of 200 Accreditation Council for Graduate Medical Education-accredited programs (3,694 residents). The 52 excluded programs had no usable information in the Residency Explorer Tool or on an identifiable program website. Overall, 15.9% of residents in orthopaedic surgery residency programs were women and 14% were under-represented minorities. The rates of female PDs and chairs were 12.4% and 6.9%, respectively, whereas those of URiM PDs and chairs were 8.3% and 4.6%, respectively. Programs with more female residents were not associated with female PDs (P = .79) or URiM PDs (P = .48). Programs with a greater percentage of URiM residents were not associated with URiM PDs (P = .16). Larger programs (P = .021) and university-based programs (P = .048) had a greater percentage of female residents. Orthopaedic residency programs with visa sponsorship had a greater percentage of URiM residents (P = .017).

CONCLUSIONS

Programs with a higher percentage of female or URiM residents did not show a significant association with having female or URiM PDs. Larger programs and university-affiliated programs were more likely to have a larger percentage of female residents, whereas programs that offered visa sponsorship had a higher percentage of URiM residents.

CLINICAL RELEVANCE

This study highlights factors influencing diversity among orthopaedic surgery residents. Although the presence of female or URiM PDs does not influence the percentage of female or URiM residents, other program characteristics such as size, affiliation, and visa sponsorship offer potentially actionable insights for promoting greater diversity in orthopaedic training. Doing so may increase under-represented groups within the field and could ultimately impact patient care and improve health care equity.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Gender Equity Efforts in Sports Medicine

Great progress has been made toward gender equality in athletics, whereas true equality has not yet been realized. Concurrently, women orthopedists along with advocate men have paved the way toward gender equity in orthopedics as a whole and more specifically in sports medicine. The barriers that contribute to gender disparities include lack of exposure, lack of mentorship, stunted career development, childbearing considerations and implicit gender bias and overt gender discrimination.

Trends in Orthopaedic Surgery Workforce Diversity: Analyzing Changes Over Time

INTRODUCTION

There are many reasons why orthopaedic surgeons move or change careers. We asked the questions: (1) What is the geographic distribution of orthopaedic surgeons with respect to age, sex, and race and ethnicity? (2) How has our workforce changed over time with regard to these factors? (3) Are there any patterns or trends detected regarding policy or regulatory events that coincide with these differences?

METHODS

The American Academy of Orthopaedic Surgeons surveys over 30,000 members, collecting data on demographics, age, race sex, and practice statistics. We calculated geographic distributions and evaluated these differences over time-potential influences from malpractice suits or tort reform were investigated.

RESULTS

Overall surgeon density increased over time. The largest negative changes were noted in District of Columbia, Wyoming, and North Dakota and positive changes in Colorado, South Dakota, and West Virginia. Age across all states increased (mean 1.7 years). Number of female surgeons increased in most states (4.6% to 5.7%). Number of  African Americans increased from 1.6% to 1.8%, Hispanic/LatinX from 1.8% to 2.2%, Asian from 5.5% to 6.7%, and multiracial from 0.8% to 1.2%. No change was noted in the percentage of Native American surgeons.

DISCUSSION

Surgeon density increased from 2012 to 2018; the cause for this change was not evident. Small increases in surgeon population, female surgeons, and in some underrepresented minorities were seen.

Diversity in Orthopaedic Surgery: What Is Next? What is Needed Collectively? How Do You Go About Effecting Positive Change?

Orthopedic surgery as a field is the least diverse medical specialty. Multiple factors contribute to the lack of diversity, including lack of diversity in medical school, lack of role models and mentors, and discrimination and bias. Addressing the lack of diversity includes use of data, implementation of targeted pipeline programs, individual physician advocacy, institutional recruitment and DEI initiatives, and leadership from professional organizations. Targeted pipeline programs and role models and mentors are very effective in increasing diversity. Cultural change is occurring, and the future orthopaedic workforce will be more diverse.

Strengthening the Pipeline: Promoting Diversity into Orthopedic Surgery

The United States is a nation of diverse racial and ethnic origins. Athletes represent the full spectrum of the nation's population. However, the orthopedic surgeons who serve as team physicians are Caucasian and male with staggeringly few exceptions. This manuscript provides an overview of the current status and barriers to diversity among orthopedic team physicians, along with strategies to address the issue. Specifically, pipeline initiatives implemented at one academic medical school and orthopedic surgery department are summarized as potential models that can be further developed by other institutions to enhance diversity in orthopedic surgery.

Analysis of Gender Diversity Within Foot and Ankle Surgery Fellowship Programs

BACKGROUND

Women continue to be underrepresented in orthopaedic surgery. This study seeks to evaluate gender diversity of faculty and trainees at foot and ankle surgery fellowship programs.

METHODS

In this cross-sectional analysis of 49 US foot and ankle fellowship programs, all publicly available data on program faculty (as of July 2023) were collected, as well as data on current and past fellows between 2018 and 2024.

RESULTS

Of 49 programs with 195 foot and ankle surgery faculty, 26.5% (n = 13) had at least 1 female on faculty, with only 8.2% (n = 4) having female fellowship directors. Female faculty made up 9.7% (n = 19) of foot and ankle surgery faculty overall. Of 307 total fellows identified within the 6-year period, 19.5% (n = 60) were female. Geographic distribution of programs was as follows: 29% (n = 14) Northeast, 31% (n = 15) South, 19% (n = 9) Midwest, and 21% (n = 10) West. Northeast programs made up 62% of all programs with female faculty, whereas Midwest programs made up the least at 8% (P = .048). Programs with female faculty had more female fellows from 2018 to 2024 than programs without female faculty (33.7% vs 14%, P < .001).

CONCLUSION

Our findings suggest that females remain underrepresented in foot and ankle surgery fellowship director positions, despite an increasing proportion of females entering orthopaedic surgery. Foot and ankle surgery fellowship programs with female faculty had a higher number of female trainees; as such, diversification of foot and ankle fellowship departments may be an important factor in ongoing efforts to promote gender diversity within the specialty.

LEVEL OF EVIDENCE

Level IV, observational cross-sectional analysis.

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.

Impact of Mentoring for Underrepresented Groups in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

Despite efforts to mitigate challenges to advance underrepresented groups (URG) groups' representation in medical education, diversity remains underwhelming. In response to this several mentoring programs to increase diversification within medical education have been implemented. However, the impact of these programs on URG representation across disciplines is unknown. The aim of this review is to evaluate the impact of structured mentoring programs on URGs in undergraduate medical education.

DESIGN

Systematic review.

METHODS

A comprehensive search strategy was performed of electronic databases including PubMed, Ovid Medline, and EMBASE between January and September 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Both qualitative and quantitative outcomes including characteristics of the mentoring structure explored within each study were collected, and differences in study outcomes analyzed.

RESULTS

In total 17 studies were included for analysis. Mentoring within URGs resulted in an increase in research opportunities, exam performance, medical specialty applications, and residency matching. Structured feedback yielded positive experiences by both mentors and mentees participating in programs, with both emotional and cultural competence issues explored across studies included for analysis.

CONCLUSIONS

Mentoring for medical students underrepresented in medicine across mentoring relationships including peer, senior, formal, and informal structures yield positive outcomes within research, academic modules, and career pathways. Future applications of mentoring programs should consider the use of tandem mentoring from both senior and peer mentors to optimize benefits URG students derive from each mentoring relationship.

Opportunities for Increasing Diversity in Orthopaedics Through Virtual Mentorship Programs

Orthopaedic surgery lags in recruiting women and under-represented minorities (URMs). In addition, women and URMs hold fewer leadership roles across orthopaedic subspecialties. This inequity is geographically heterogeneous, with female URM residents and attendings being more concentrated in some areas of the country. For instance, practicing female orthopaedic surgeons are more prevalent in Northeast and Pacific programs. Mentorship and representation in leadership positions play a notable role in trainee recruitment. Video communication platforms offer a novel mechanism to reach historically under-represented students across the country. We reviewed five established mentorship programs focused on women and URMs. Each program emphasized a longitudinal relationship between mentors and mentees. In reviewing these programs, we sought to identify the successful components of each program. Leveraging and integrating effective components already established by conventional mentorship programs into virtual programming will aid in optimizing those programs and improve geographic equity in access to mentorship resources. It is critical to extend the principles of successful mentorship programs to technology-enabled programs moving forward.

Sex Disparities Among Fellowship Program Directors in Orthopaedic Surgery

BACKGROUND

Women are underrepresented in the orthopaedic surgery workforce in the U.S. The purpose of this study was to elucidate the representation of women among fellowship program directors (PDs) in orthopaedic surgery.

METHODS

This was a retrospective cohort study of fellowship PDs in orthopaedic surgery during the 2022 to 2023 academic year. Academic, training, and demographic characteristics were collected from internet-based resources. Participation-to-prevalence ratios (PPRs) were calculated for both men and women. A PPR of <0.8 indicated underrepresentation and a PPR of >1.2 indicated overrepresentation. Bivariate analyses were utilized to assess the correlation between sex diversity and geographic region and between sex diversity and Accreditation Council for Graduate Medical Education (ACGME)-accreditation status. The relationship between the median annual salary and the sex diversity of each orthopaedic subspecialty was analyzed with use of the Pearson correlation coefficient.

RESULTS

This study included 600 fellowship PDs, 40 (6.7%) of whom were women. In total, 24.5% of the fellowship PDs were assistant professors (8.8% women versus 91.2% men, p < 0.001); 26.2% were associate professors (9.6% women versus 90.4% men, p < 0.001); 36.8% were full professors (4.5% women versus 95.5% men, p < 0.001); and 12.5% were unranked (2.7% women versus 97.3% men, p < 0.001). The representation of women increased with academic rank, as reflected in their prevalence at the assistant (PPR = 0.67), associate (PPR = 0.77), and full professor (PPR = 0.80) levels. Among the orthopaedic subspecialties, musculoskeletal oncology (19.0%), pediatric orthopaedics (14.6%), and hand surgery (12.6%) had the highest proportions of women fellowship PDs. PPRs were lowest for orthopaedic sports medicine (PPR = 0.35), shoulder and elbow (PPR = 0.45), and adult reconstruction (PPR = 0.52). Women PDs had equitable representation in musculoskeletal oncology (PPR = 1.17), hand surgery (PPR = 1.02), foot and ankle (PPR = 0.84), and orthopaedic trauma (PPR = 0.80). Median subspecialty compensation was negatively correlated with the prevalence of women among fellowship PDs (r = -0.70, p = 0.036). Geographic region was not associated with sex diversity (p = 0.434), but programs with ACGME accreditation had significantly more women fellowship PDs than those without (11.0% versus 3.9%, p < 0.001).

CONCLUSIONS

Women are underrepresented among orthopaedic fellowship PDs, especially in certain subspecialties (orthopaedic sports medicine, shoulder and elbow, and adult reconstruction). More research is needed to understand the barriers that impact the representation of women among leadership positions in orthopaedic surgery.

CLINICAL RELEVANCE

Greater sex diversity among fellowship PDs may help to increase the recruitment of women into orthopaedic subspecialties. The equitable consideration of orthopaedic surgeons from all backgrounds for leadership positions can increase workforce diversity, which may improve the vitality of the orthopaedic community.

Workforce diversity in cardiothoracic surgery: An examination of recent demographic changes and the training pathway

INTRODUCTION

The purpose of our study was to examine changes in the demographic makeup of resident physicians in integrated 6-year cardiothoracic surgery and traditional thoracic surgery residency programs from 2013 to 2022 compared with other surgical subspecialties and determine potential leaks in the training pathway.

METHODS

Data from US Graduate Medical Education reports from 2013 to 2022 and medical student enrollment data from the Association of American Medical Colleges were obtained. Average percentages of women and underrepresented minorities were calculated in 2 5-year intervals: 2013 to 2017 and 2018 to 2022. Average percentages of women, Black, and Hispanic medical students and residents were calculated for the 2019 to 2022 period. Pearson χ2 tests were conducted to determine significant differences in proportions of women, Black/African American, and Hispanic trainees across time (α = 0.05).

RESULTS

Thoracic surgery and I6 residents saw a significant increase in the proportion of women trainees across the 2 time periods (19.9% (210 out of 1055) to 24.6% (287 out of 1169) (P < .01) and 24.1% (143 out of 592) to 28.9% (330 out of 1142) (P < .05)), respectively. There was no significant change in the proportion of Black and Hispanic trainees in thoracic surgery fellowship or integrated 6-year cardiothoracic residency programs. Hispanic trainees were the only group whose proportion of cardiothoracic surgery trainees was not significantly lower than their medical school proportion. Women and Black trainees had significantly lower proportions of thoracic surgery residents and integrated 6-year cardiothoracic residency program residents than their proportions in medical school (P < .01).

CONCLUSIONS

Cardiothoracic surgery has not significantly increased the number of Black and Hispanic trainees during the past decade. The lower proportion of Blacks and women in thoracic surgery residency and fellowship programs compared with their proportion in medical schools is concerning and is an opportunity for intervention.

Analysis of Academic Accomplishments and Demographics for Elected Presidents of National Orthopedic Surgery Organizations in the United States

This study analyzed the academic accomplishments and demographics of elected presidents of the American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Association (AOA), and American Board of Orthopaedic Surgery (ABOS). Curriculum vitae and internet-based resources were reviewed to collect demographics, training characteristics, bibliometrics, and National Institutes of Health (NIH) research funding of contemporary presidents (1990-2020). Eighty presidents were included. Most presidents were men (97%), and 4% of presidents were non-White (3% Black and 1% Hispanic). Few had an additional graduate degree (4% MBA, 3% MS, 1% MPH, 1% PhD). Ten orthopedic surgery residency programs trained 47% of these presidents. Most had fellowship training (59%), and the top three were hand surgery (11%), pediatric orthopedics (11%), and adult reconstruction (10%). Twenty-nine presidents (36%) participated in a traveling fellowship. The mean age at appointment was 58±5 years, which was 27 years since residency graduation. The mean h-index was 36±23, resulting from 150±126 peer-reviewed manuscripts. Orthopedic surgery presidents had more peer-reviewed manuscripts (150±126) than chairs (73±81) and program directors (27±32) (P<.001). AOA presidents had the highest mean h-index (42±21) compared with AAOS (38±27) and ABOS (25±16) presidents (P=.035). Nineteen presidents had NIH funding (24%). More presidents had NIH funding in the AOA (39%) and AAOS (25%) than the ABOS (0%) (P=.007). Orthopedic surgery presidents possess high levels of scholarly output. AOA presidents had the highest h-index values and prevalence of NIH funding. Females and racial minorities remain underrepresented at the highest levels of leadership. [Orthopedics. 2024;47(1):e45-e51.].

AOA Critical Issues: Perceptions on the State of Diversity, Equity, and Inclusion in Orthopaedic Surgery: A Survey of the AOA Membership

BACKGROUND

Orthopaedic surgery continues to trail other specialties in increasing diversity among its physician workforce. Various efforts have been and are currently being made to not only increase diversity, but also promote equity and inclusion in the field. The purpose of this study was to survey members of the American Orthopaedic Association (AOA) to determine how leaders in orthopaedics view diversity, equity, and inclusion (DEI) at the present time and to understand their perspective while moving into the future.

METHODS

An anonymous 11-question survey was disseminated online to AOA members in May 2022. These individuals were identified by the AOA membership directory and the email ListServe. The survey included free-response and multiple-choice questions. Demographic information was self-identified, and both qualitative and quantitative data were collected.

RESULTS

Of the 1,657 AOA members who were provided the survey, 262 (15.8%) responded. Approximately 29.5% (77) and 45.6% (119) of the surveyed population ranked "retention of underrepresented populations in orthopaedic residency (women, URiM)" as "very important" or "absolutely essential," respectively. The answers to the free-response questions identified multiple core themes that responders were passionate about, namely resident and attending physician recruitment and retention, as well as resident selection.

CONCLUSIONS

Leaders in the field of orthopaedic surgery desire for action to be taken in the field of DEI. The findings of this survey denote positive attitudes even though many inequalities still pervade the field of orthopaedics. Through mentorship, objective evaluation, transparency, and continued intentional action, orthopaedic surgery is well-positioned to continue to move forward with DEI.

Overcoming the Barriers to Diversity in Orthopaedic Surgery: A Global Perspective

BACKGROUND

Diversity in orthopaedics continues to lag behind that in other surgical specialties. This pattern exists globally and is not unique to gender or race. This review offers a global perspective on overcoming the barriers to diversity in orthopaedics.

METHODS

A literature search of MEDLINE and Embase was conducted and a narrative review was undertaken. Publications that discussed any aspect of diversity or solutions to diversity within orthopaedics or academic orthopaedics were identified.

RESULTS

A total of 62 studies were included. Studies showed that diversity in orthopaedic training is limited by structural barriers such as long hours, requirements to relocate during training, training inflexibility, and a lack of exposure to orthopaedics. Implicit bias during the selection process for training, discrimination, and a lack of role models are additional barriers that are experienced by both minority and female surgeons. The global lack of diversity suggests that there are also inherent "cultural barriers" that are unique to orthopaedics; however, these barriers are not uniformly experienced. Perceptions of orthopaedics as promoting an unhealthy work-life balance and the existence of a "boys' club" must be addressed. Strong, committed leaders can embed cultural norms, support trainees, and act as visible role models. Targeted efforts to increase diverse recruitment and to reduce bias in selection processes for medical school and specialty training will increase diversity in the "training pipeline."

CONCLUSIONS

Diversity in orthopaedics continues to lag behind that in other specialties. Increasing diversity is important for providing a more inclusive training environment, improving patient care, and reducing health disparities. Structural and cultural barriers need to be addressed to improve diversity in orthopaedics. Promoting a culture supportive of all surgeons is essential to reframing perceptions that may prevent individuals from even considering a career as an orthopaedic surgeon. Changing attitudes require focused efforts from committed leadership in a "top-down" approach that prioritizes diversity. The efforts from national bodies seeking to tackle the lack of diversity, as well as the establishment of organizations committed to diversity, such as the International Orthopaedic Diversity Alliance, provide reasons to be optimistic for the future.

Underrepresentation of African Americans in Plastic Surgery: Examining Demographics, Specialty Factors, and Medical School Experiences

BACKGROUND

Racial representation among medical trainees translates into physicians that are able to communicate with diverse patient populations and are perceptive to health disparities. This is important within plastic surgery where an optimal physicianpatient relationship is essential to health outcomes.

OBJECTIVE

The purpose of this study is to address underrepresentation of African Americans (AA) in plastic surgery through improving understanding of factors that may contribute to AA medical student interest in plastic surgery.

DESIGN

This was a voluntary, cross-sectional survey. An online survey was designed to collect information on demographics, specialty factor importance, medical school experiences, and plastic surgery interest among medical students. The survey was distributed to medical students within three national medical organizations between August 2018 and February 2019. The following groups of respondents were statistically COMPARED: AAs interested vs. AAs not interested in plastic surgery and AA vs. Caucasian medical students both interested in plastic surgery.

SETTING

Online survey for medical students in the United States.

PARTICIPANTS

All 428 participants were medical students that belonged to at least 1 of the 3 national medical organizations between August 2018 and February 2019.

RESULTS

The survey was completed by 428 participants of which 142 were excluded for incomplete surveys, leaving 286 (66.8%) participants to be included in the study. Among AA medical students, 128 (75.3%) were not interested in Plastic Surgery and 42 (24.7%) were interested. The 2 groups were similar demographically but differed significantly across multiple specialty factors and medical school experiences (p < 0.05). When compared to interested Caucasian medical students (n = 30), interested AA medical students differed significantly in demographics, specialty factors, and medical school experiences (p < 0.05).

CONCLUSIONS

This study supports the implementation of medical school interventions emphasizing specialty factors and medical school experiences unique to AA medical students interested in plastic surgery to promote their application into the specialty.

Rapidly Increasing Number and Cost of Residency Applications in Surgery

BACKGROUND

Surgical specialties represent the most competitive residency positions to obtain, and applicants for these spots may apply to increasingly more programs in an attempt to match. We describe trends in residency applications across all surgical specialties from 2017 to 2021 application cycles.

MATERIALS AND METHODS

This review of the 2017, 2018, 2019, 2020, and 2021 surgical residency application cycles used the American Association of Medical Colleges' Electronic Residency Application Service (ERAS) databases. Data from a total of 72,171 applicants to United States surgical residencies during the study's time period were included. The 2021 ERAS fee schedule was used to calculate the cost of applications.

RESULTS

The number of applicants across the study interval remains unchanged. Trends suggest more women and underrepresented minorities in medicine are applying to surgical residencies today compared to 5 years ago. The mean number of applications per applicant increased 32.0% from 39.3 in 2017 to 51.8 in 2021, resulting in an increased application fee cost of $329 per applicant. Mean total cost for application fees alone in 2021 were $1211 per applicant. In 2021, the cost of applying to surgical residency for all applicants was over $26 million, a nearly $8 million increase from 2017.

CONCLUSIONS

There has been an increase in the number of applications per applicant in the past 5 residency application cycles. Increased applications create barriers and burdens for applicants, and residency program personnel. These rapid increases are unsustainable and require intervention, although a viable solution has yet to be elucidated.

What are the Trends in Racial Diversity Among Orthopaedic Applicants, Residents, and Faculty?

BACKGROUND

Orthopaedic surgery has recruited fewer applicants from underrepresented in medicine (UIM) racial groups than many other specialties, and recent studies have shown that although applicants from UIM racial groups are competitive for orthopaedic surgery, they enter the specialty at lower rates. Although previous studies have measured trends in orthopaedic surgery applicant, resident, or attending diversity in isolation, these populations are interdependent and therefore should be analyzed together. It is unclear how racial diversity among orthopaedic applicants, residents, and faculty has changed over time and how it compares with other surgical and medical specialties.

QUESTIONS/PURPOSES

(1) How has the proportion of orthopaedic applicants, residents, and faculty from UIM and White racial groups changed between 2016 and 2020? (2) How does representation of orthopaedic applicants from UIM and White racial groups compare with that of other surgical and medical specialties? (3) How does representation of orthopaedic residents from UIM and White racial groups compare with that of other surgical and medical specialties? (4) How does representation of orthopaedic faculty from UIM and White racial groups compare with that of other surgical and medical specialties?

METHODS

We drew racial representation data for applicants, residents, and faculty between 2016 and 2020. Applicant data on racial groups was obtained for 10 surgical and 13 medical specialties from the Association of American Medical Colleges Electronic Residency Application Services report, which annually publishes demographic data on all medical students applying to residency through Electronic Residency Application Services. Resident data on racial groups were obtained for the same 10 surgical and 13 medical specialties from the Journal of the American Medical Association Graduate Medical Education report, which annually publishes demographic data on residents in residency training programs accredited by the Accreditation Council for Graduate Medical Education. Faculty data on racial groups were obtained for four surgical and 12 medical specialties from the Association of American Medical Colleges Faculty Roster United States Medical School Faculty report, which annually publishes demographic data of active faculty at United States allopathic medical schools. UIM racial groups include American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native American or Other Pacific Islander. Chi-square tests were performed to compare representation of UIM and White groups among orthopaedic applicants, residents, and faculty between 2016 and 2020. Further, chi-square tests were performed to compare aggregate representation of applicants, residents, and faculty from UIM and White racial groups in orthopaedic surgery to aggregate representation among other surgical and medical specialties with available data.

RESULTS

The proportion of orthopaedic applicants from UIM racial groups increased between 2016 to 2020 from 13% (174 of 1309) to 18% (313 of 1699, absolute difference 0.051 [95% CI 0.025 to 0.078]; p < 0.001). The proportion of orthopaedic residents (9.6% [347 of 3617] to 10% [427 of 4242]; p = 0.48) and faculty (4.7% [186 of 3934] to 4.7% [198 of 4234]; p = 0.91) from UIM racial groups did not change from 2016 to 2020. There were more orthopaedic applicants from UIM racial groups (15% [1151 of 7446]) than orthopaedic residents from UIM racial groups (9.8% [1918 of 19,476]; p < 0.001). There were also more orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) than orthopaedic faculty from UIM groups (4.7% [992 of 20,916], absolute difference 0.051 [95% CI 0.046 to 0.056]; p < 0.001). The proportion of orthopaedic applicants from UIM groups (15% [1151 of 7446]) was greater than that of applicants to otolaryngology (14% [446 of 3284], absolute difference 0.019 [95% CI 0.004 to 0.033]; p = 0.01), urology (13% [319 of 2435], absolute difference 0.024 [95% CI 0.007 to 0.039]; p = 0.005), neurology (12% [1519 of 12,862], absolute difference 0.036 [95% CI 0.027 to 0.047]; p < 0.001), pathology (13% [1355 of 10,792], absolute difference 0.029 [95% CI 0.019 to 0.039]; p < 0.001), and diagnostic radiology (14% [1635 of 12,055], absolute difference 0.019 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from that of applicants to neurosurgery (16% [395 of 2495]; p = 0.66), plastic surgery (15% [346 of 2259]; p = 0.87), interventional radiology (15% [419 of 2868]; p = 0.28), vascular surgery (17% [324 of 1887]; p = 0.07), thoracic surgery (15% [199 of 1294]; p = 0.94), dermatology (15% [901 of 5927]; p = 0.68), internal medicine (15% [18,182 of 124,214]; p = 0.05), pediatrics (16% [5406 of 33,187]; p = 0.08), and radiation oncology (14% [383 of 2744]; p = 0.06). The proportion of orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) was greater than UIM representation among residents in otolaryngology (8.7% [693 of 7968], absolute difference 0.012 [95% CI 0.004 to 0.019]; p = 0.003), interventional radiology (7.4% [51 of 693], absolute difference 0.025 [95% CI 0.002 to 0.043]; p = 0.03), and radiation oncology (7.9% [289 of 3659], absolute difference 0.020 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from UIM representation among residents in plastic surgery (9.3% [386 of 4129]; p = 0.33), urology (9.7% [670 of 6877]; p = 0.80), dermatology (9.9% [679 of 6879]; p = 0.96), and diagnostic radiology (10% [2215 of 22,076]; p = 0.53). The proportion of orthopaedic faculty from UIM groups (4.7% [992 of 20,916]) was not different from UIM representation among faculty in otolaryngology (4.8% [553 of 11,413]; p = 0.68), neurology (5.0% [1533 of 30,871]; p = 0.25), pathology (4.9% [1129 of 23,206]; p = 0.55), and diagnostic radiology (4.9% [2418 of 49,775]; p = 0.51). Compared with other surgical and medical specialties with available data, orthopaedic surgery had the highest proportion of White applicants (62% [4613 of 7446]), residents (75% [14,571 of 19,476]), and faculty (75% [15,785 of 20,916]).

CONCLUSION

Orthopaedic applicant representation from UIM groups has increased over time and is similar to that of several surgical and medical specialties, suggesting relative success with efforts to recruit more students from UIM groups. However, the proportion of orthopaedic residents and UIM groups has not increased accordingly, and this is not because of a lack of applicants from UIM groups. In addition, UIM representation among orthopaedic faculty has not changed and may be partially explained by the lead time effect, but increased attrition among orthopaedic residents from UIM groups and racial bias likely also play a role. Further interventions and research into the potential difficulties faced by orthopaedic applicants, residents, and faculty from UIM groups are necessary to continue making progress.

CLINICAL RELEVANCE

A diverse physician workforce is better suited to address healthcare disparities and provide culturally competent patient care. Representation of orthopaedic applicants from UIM groups has improved over time, but further research and interventions are necessary to diversify orthopaedic surgery to ultimately provide better care for all orthopaedic patients.

A 25-Year Analysis of Diversity, Equity, and Inclusion Research in Orthopaedics Shows Majority Female Authorship and Increasing Gender Parity Research

Introduction

Orthopaedic surgery is one of the least diverse fields in medicine. In recent decades, there has been a concerted effort to increase diversity, equity, and inclusion (DEI) in the specialty, in addition to the institution of several organizations to establish the pipeline and facilitate underrepresented minority students into orthopaedic surgery. The aim of this study was to examine trends in orthopaedic surgery DEI research.

Methods

A search of DEI articles was conducted in orthopaedic surgery using PubMed, MEDLINE, EMBASE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center. The year of publication, article topic of focus, sex of the primary author, publishing journal, citation index, and primary contributing institution were recorded for each article. Sex of the primary author was predicted by the authors using an online image search of the author and institution. Articles were excluded if the research was conducted outside of the United States or if they were not specific to orthopaedic surgery.

Results

A total of 143 articles met the inclusion criteria. A total of 52.4% of authors (n = 75) were women and 44.1% (n = 63) were men. A total of 42.7% of the articles were written about sex (n = 61), 39.9% about race/ethnicity and sex (n = 57), and 11.9% about race/ethnicity (n = 17). A total of 10 articles were affiliated with Washington University in St. Louis while 51 other institutions wrote the remaining articles, with none having more than 4. Information could not be confirmed for 5 articles. In 2018, 5 articles were published, followed by 17 in 2019, 25 in 2020, 34 in 2021, and 30 in 2022.

Conclusion

DEI research in orthopaedic surgery is a relatively new venture within the specialty and has room to grow, specifically in the examination of race/ethnicity and inclusion strategies. Leading journals and academic institutions in orthopaedic surgery should incentivize productivity and authorship in DEI research.

Level of Evidence

III.

Gender equality challenges in orthopaedic surgery: a systematic review

PURPOSE

Several studies have examined gender-equality challenges and ways to improve women's representation and management. Orthopaedic surgeons and patients are less gender equitable than them of other surgical disciplines. This systematic review summarizes these findings and highlights orthopaedic surgery gender inequality.

METHODS

Search of the PubMed, Embase, and Cochrane databases was carried out to extract human studies investigating the gender gap in orthopaedics, trying to highlight the equality challenges orthopaedic surgery faces. Studies incorporating patients with comorbidities in which gender is a proven risk factor, and pregnant women were excluded.

RESULTS

This systematic review included 59 studies involving 692,435 people (mean females/males ratio: 4.44), spanning the years 1987-2023. Regarding the targeted population, 35 (59.32%) studies focused on patients, while 24 (40.68%) on physicians. Orthopaedic surgery is described as an unfriendly career field for women as surgeons or sports leading physicians while women are generally under represented in the academic field of orthopaedics. Regarding patients, female gender consists both a risk and prognostic factor influencing the prevalence of degenerative disease and the outcome of the operative treatment in reconstructive orthopaedics. Female gender is a risk factor for multiple sports injuries and influences the pathogenetic mechanisms resulting in ACL reconstruction. Regarding spine surgery, women are less likely to have surgery suggested, and such suggestion underlines severe disease's progression.

CONCLUSIONS

Gender differences affect orthopaedic patient-physician-healthcare system interactions. Recognizing biases and their patterns is useful to improve the actual situation. By preventing those an unbiased, tolerant, and egalitarian workplace for physicians and a healthcare system that provides the best treatment to patients could be created.

Factors That Influence Orthopedic Women Residents' Selection of Adult Reconstruction

BACKGROUND

Stereotypes may discourage women from going into the historically male-dominated field of Adult Reconstruction. Other factors such as interest, confidence, and a sense of belonging may influence subspecialty choice. The objective of this study was to survey orthopedic surgery residents regarding their perceptions about Adult Reconstruction.

METHODS

A validated survey evaluating social determinants of behavior was adapted to assess orthopedic surgery residents' perceptions of Adult Reconstruction. The survey was electronically distributed to residents from 16 United States and Canadian Accreditation Council for Graduate Medical Education-accredited residency programs. There were 93 respondents including 39 women (42%) and 54 men (58%). Study data were collected and managed using an electronic data capture tool. Descriptive statistics were reported for all continuous variables. Percentiles and sample sizes were reported for categorical variables.

RESULTS

Women and men reported similar interest in Adult Reconstruction (46% versus 41%, P = .60). Fewer women reported that they were encouraged to go into Adult Reconstruction by faculty (62% versus 85%, P = .001). Women and men reported similar confidence in their own ability to succeed in the subspecialty of Adult Reconstruction. However, when asked about the ability of other residents, both sexes rated men as having higher levels of confidence. Women and men perceived other residents and faculty felt "men are better Adult Reconstruction surgeons," but did not personally agree with this statement.

CONCLUSION

Women and men residents expressed similar rates of interest and self-confidence in Adult Reconstruction, but there were social barriers including negative stereotypes that may prevent them from pursuing careers in Adult Reconstruction.

Gender Diversity in Sports Medicine: Current Trends

As the sports medicine field has grown, the need for a more diverse workforce has become more evident. Given the growing athlete diversity that exists at all recreational and competitive levels of organized sports, it is important to better understand the current state of athletic health care diversity. This review assesses the current state of diversity in sports medicine from the perspective of the medical and athletic training professions. Men and women currently display nearly equivalent participation levels; however, the distribution of female team physicians and athletic trainers could better match the teams that they serve. Although progress has been made, much more needs to be done to bring more female athletic trainers and team physicians into athletic health care leadership roles. Early mentoring programs have shown efficacy for increasing the number of female candidates who might become the foundation of future athletic health care and academic program leaders.

Level of Evidence

V, expert opinion.

Use of Simulation Resources for Underrepresented in Medicine Youth Engagement: A National Survey of Academic Anesthesiology Programs With Specified Diversity, Equity, and Inclusion Positions

Background The utilization of simulation resources can be an effective strategy to offer early medical exposure to underrepresented in medicine (URiM) youth populations, with the objective of promoting diversity in the field of medicine. Currently, it is unclear what proportion of academic anesthesiology programs with simulation centers utilize these resources for community engagement events. Methodology A survey was created using REDCap® and distributed via email to 38 anesthesiologists from 30 departments in the United States holding a leadership position dedicated to advancing diversity, equity, and inclusion. The survey assessed whether their programs had conducted community engagement events for URiM students, what simulation resources were available at their program, and which of these resources they had used at any community engagement events. Additionally, we assessed program characteristics such as region, academic versus community practice, and urban versus rural locations. Survey responses were collected between March and April 2023. Results We received responses from 15 of the 30 institutions sampled for an institutional response rate of 50%. The majority of respondents (86.7%) reported holding community engagement events. Most respondents reported a wide variety of simulation resources available, including 11 (73.3%) having access to full simulation centers. However, only three (27.3%) of the 11 with full simulation centers reported utilizing them for community events. Conclusions Despite the potential benefits of using simulation resources for community engagement events, our results suggest that academic anesthesiology departments may not commonly utilize simulation centers to provide URiM youth with exposure to the field of medicine. Anesthesiology departments with access to simulation resources are in a unique position to be leaders in advancing diversity in medicine by increasing URiM youth interest in medicine as a career through simulation-based exposure.

Diversity-Related Positions in Orthopaedic Surgery Residency Programs

Background

The Association of American Medical Colleges and the American Academy of Orthopaedic Surgeons have incorporated diversity and inclusion as one of their primary goals. Orthopaedic surgery remains the least diverse medical specialty when measured for practicing physicians and trainees. The purpose of this study was to determine the number and distinct types of diversity, equity, and inclusion (DEI) positions within orthopaedic surgery residency programs in the United States.

Methods

The Fellowship and Residency Electronic Interactive Database was used to obtain a list of all Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs. The following was collected from 193 residency program websites between June 6, 2022, and June 26, 2022: program location, university or community based, allopathic or osteopathic recognition, number of faculty in the orthopaedic department, number of residents per year, diversity-related statements, and diversity-focused faculty positions.

Results

Of the 193 programs evaluated, 74 (38.9%) included DEI statements on their website while only 42 (21.8%) had at least one DEI-specific faculty role (e.g., diversity committee, diversity liaison, vice chair for DEI). For 16 (8.3%) programs, the faculty role was nonspecific to the orthopaedic residency program. Nonspecific roles were primarily created by the affiliated school of medicine, but in 4 (2.1%) outlier cases, faculty members assumed DEI roles through a medical center, a graduate medical education program, or a department of surgery.

Conclusions

Less than half of orthopaedic surgery residency programs currently advocate for DEI on their associated websites while fewer than 25% have a DEI faculty position. Previous studies have called for a greater number of DEI positions and committees among orthopaedic residencies because of the lower admittance rate of qualified Under Represented in Medicine (URiM) applicants. A role dedicated to DEI may increase the number of women and URiM applicants pursuing a career in orthopaedic surgery.

Assessment of Demographic Changes of Workforce Diversity in Otolaryngology, 2013 to 2022

Importance

Given the growth of minoritized groups in the US and the widening racial and ethnic health disparities, improving diversity remains a proposed solution in the field of otolaryngology. Evaluating current trends in workforce diversity may highlight potential areas for improvement.

Objective

To understand the changes in gender, racial, and ethnic diversity in the otolaryngology workforce in comparison with changes in the general surgery and neurosurgery workforces from 2013 to 2022.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges for 2013 to 2022, and included medical students and trainees in all US medical residency programs and allopathic medical schools.

Main Outcomes and Measures

Average percentages of women, Black, and Latino trainees during 2 intervals of 5 years (2013-2017 and 2018-2022). Pearson χ2 tests compared demographic information. Normalized ratios were calculated for each demographic group in medical school and residency. Piecewise linear regression assessed linear fit for representation across time periods and compared rates of change.

Results

The study population comprised 59 865 medical residents (43 931 [73.4%] women; 6203 [10.4%] Black and 9731 [16.2%] Latino individuals; age was not reported). The comparison between the 2 study intervals showed that the proportions of women, Black, and Latino trainees increased in otolaryngology (2.9%, 0.7%, and 1.6%, respectively), and decreased for Black trainees in both general surgery and neurosurgery (-0.4% and -1.0%, respectively). In comparison with their proportions in medical school, Latino trainees were well represented in general surgery, neurosurgery, and otolaryngology (normalized ratios [NRs]: 1.25, 1.06, and 0.96, respectively); however, women and Black trainees remained underrepresented in general surgery, neurosurgery, and otolaryngology (women NRs, 0.76, 0.33, and 0.68; Black NRs, 0.63, 0.61, and 0.29, respectively). The percentage of women, Black, and Latino trainees in otolaryngology all increased from 2020 to 2022 (2.5%, 1.1%, and 1.1%, respectively). Piecewise regression showed positive trends across all 3 specialties.

Conclusions and Relevance

The findings of this cross-sectional study indicate a positive direction but only a modest increase of diversity in otolaryngology, particularly in the context of national demographic data. Novel strategies should be pursued to supplement existing efforts to increase diversity in otolaryngology.

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.

Continued underrepresentation of historically excluded groups in the neurosurgery pipeline: an analysis of racial and ethnic trends across stages of medical training from 2012 to 2020

OBJECTIVE

US allopathic medical schools have experienced improvements in racial and ethnic diversity among matriculants in the past decade. It is not clear, however, whether better representation of historically excluded racial and ethnic groups at medical school entry impacts subsequent stages of the medical training pipeline leading into a specific field. The aim of this study was to examine these trends as they relate to the neurosurgical medical education pipeline and consider the drivers that sustain barriers for underrepresented groups.

METHODS

Race and ethnicity reports from the American Association of Medical Colleges were obtained on allopathic medical school applicants, acceptees, and graduates and applicants to US neurosurgical residency programs from 2012 to 2020. The representation of groups categorized by self-reported race and ethnicity was compared with their US population counterparts to determine the representation quotient (RQ) for each group. Annual racial composition differences and changes in representation over time at each stage of medical training were evaluated by estimating incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using non-Hispanic Whites as the reference group.

RESULTS

On average, Asian and White individuals most frequently applied and were accepted to medical school, had the highest graduation rates, and applied to neurosurgery residency programs more often than other racial groups. The medical school application and acceptance rates for Black individuals increased from 2012 to 2020 relative to Whites by 30% (95% CI 1.23-1.36) and 42% (95% CI 1.31-1.53), respectively. During this same period, however, inequities in neurosurgical residency applications grew across all non-Asian racialized groups relative to Whites. While the incidence of active Black neurosurgery residents increased from 2012 to 2020 (0.6 to 0.7/100,000 Black US inhabitants), the prevalence of White neurosurgery residents grew in the active neurosurgery resident population by 16% more.

CONCLUSIONS

The increased racial diversity of medical school students in recent years is not yet reflected in racial representation among neurosurgery applicants. Disproportionately fewer Black relative to White US medical students apply to neurosurgery residency, which contributes to declining racial representation among all active neurosurgery resident physicians. Hispanic individuals are becoming increasingly represented in neurosurgery residency but continue to remain underrepresented relative to the US population. Ongoing efforts to recruit medical students into neurosurgery who more accurately reflect the diversity of the general US population are necessary to ensure equitable patient care.