Racial Diversity in Orthopedic Surgery

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.

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.

Cytopathology fellowship and practice: Are our trainees and cytopathologists diverse?

Over the last several years, there has been increased focus on diversity, equity, and inclusion within all areas of pathology and laboratory medicine. Many of the specialty societies within pathology have taken up the mantle of diversity. While there is little research into the diversity of cytopathologists in practice, the Accreditation Council for Graduate Medical Education (ACGME) has been collecting diversity data on pathology and laboratory medicine trainees since 2011. This data are an opportunity to explore how diverse our trainees in cytopathology are, and by extrapolation, allows us to develop some ideas as to how diverse attending level cytopathologists are. The author will also share personal observations from her own training and career regarding diversity in cytopathology.

How Did Black and Hispanic Orthopaedic Applicants and Residents Compare to General Surgery Between 2015 and 2022?

BACKGROUND

Despite the heavy demand for and knowledge of the benefits of diversity, there is a persistent lack of racial, ethnic, and gender diversity in orthopaedic surgery. Since the implementation of diversity initiatives, data have shown that general surgery has been one of the top competitive surgical fields and has demonstrated growth in racial, ethnic, and gender diversity, making general surgery a good point of reference and comparison when analyzing racial and ethnic growth in orthopaedic surgery.

QUESTIONS/PURPOSES

(1) What were the growth rates for Black and Hispanic orthopaedic residency applicants and residents between 2015 and 2022? (2) How did the growth rates of Black and Hispanic individuals in orthopaedic surgery compare with those of general surgery? (3) How did applicant recruitment and resident acceptance differ between Black and Hispanic people in orthopaedic surgery?

METHODS

Applicant data were obtained from historical specialty-specific data from the Association of American Medical Colleges Electronic Residency Application Service Statistics database between 2018 and 2022, and resident data were obtained from the Accreditation Council of Graduate Medical Education Data Resource Book between 2015 and 2021. Between 2018 and 2022, the number of residency applicants totaled 216,677, with 17,912 Black residency applicants and 20,413 Hispanic residency applicants. Between 2015 and 2021, the number of active residents totaled 977,877, with 48,600 Black residents and 62,605 Hispanic residents. Because the applicant and resident data do not overlap throughout all years of observation, a sensitivity analysis of overlapping years (between 2018 and 2021) was conducted to ensure observed trends were consistent and valid throughout the study. All datasets obtained were used to establish the different racial and ethnic proportions of Black and Hispanic residency applicants and residents in four nonsurgical primary care specialties and four surgical subspecialties. A reference slope was created using data from the Association of American Medical Colleges and Accreditation Council of Graduate Medical Education to represent the growth rate for total residency applicants and residents, independently, across all residency specialties reported in each database. This slope was used for comparison among the resident and applicant growth rates for all eight selected specialties. Datapoints were placed into a scatterplot with regression lines, using slope equations to depict rate of growth and R 2 values to depict linear fit. Applicant growth corresponded to applicant recruitment and resident growth corresponded to resident acceptance. Chi-square tests were used to compare residents and residency applicants for the Black and Hispanic populations, separately. Two-way analysis of variance with a time-by-specialty interaction term (F-test) was conducted to determine differences between growth slopes.

RESULTS

There was no difference in the growth rate of Black orthopaedic surgery applicants between 2018 and 2022, and there was no difference in the growth rate of Hispanic orthopaedic surgery applicants (R 2 = 0.43; p = 0.23 and R 2 = 0.63; p = 0.11, respectively). However, there was a very slight increase in the growth rate of Black orthopaedic surgery residents between 2015 and 2021, and a very slight increase in the growth rate of Hispanic orthopaedic surgery residents (R 2 = 0.73; p = 0.02 and R 2 = 0.79; p = 0.01, respectively). There were no differences in orthopaedic and general surgery rates of growth for Black applicants between 2018 and 2022 (0.004 applicants/year versus -0.001 applicants/year; p = 0.22), and no differences were found in orthopaedic and general surgery rates of growth for Black residents between 2015 and 2021 (0.003 residents/year versus 0.002 residents/year; p = 0.59). Likewise, Hispanic orthopaedic applicant growth rates did not differ between 2018 and 2022 from the rates of general surgery (0.004 applicants/year versus 0.005 applicants/year; p = 0.68), and there were no differences in orthopaedic and general surgery rates of growth for Hispanic residents (0.007 residents/year versus 0.01 residents/year; p = 0.35). Furthermore, growth rate comparisons between Black orthopaedic applicants and residents between 2018 and 2021 showed applicant growth was larger than resident growth, illustrating that the recruitment of Black applicants increased slightly more rapidly than resident acceptance. Growth rate comparisons between Hispanic applicants and residents showed a larger rate of resident growth, illustrating Hispanic resident acceptance increased slightly faster than applicant recruitment during that time.

CONCLUSION

We found low acceptance of Black residents compared with the higher recruitment of Black applicants, as well as overall low proportions of Black and Hispanic applicants and residents. Future studies might explore the factors contributing to the higher acceptances of Hispanic orthopaedic residents than Black orthopaedic residents.

CLINICAL RELEVANCE

We recommend that more emphasis should be placed on increasing Black and Hispanic representation at the department level to ensure cultural considerations remain at the forefront of applicant recruitment. Internal or external reviews of residency selection processes should be considered, and more immersive, longitudinal orthopaedic surgery clerkships and research mentorship experiences should be targeted toward Black and Hispanic students. Holistic reviews of applications and selection processes should be implemented to produce an increased racially and ethnically diverse applicant pool and a diverse residency work force, and implicit bias training should be implemented to address potential biases and diversity barriers that are present in residency programs and leadership.

Who Bears the Burden? Understanding the Socioeconomic Patterns of Educational Debt in Orthopaedic Surgery Residency Candidates

BACKGROUND

Educational debt is commonly observed among applicants to orthopaedic surgery residency programs; however, an understanding of the debt burden among minority and nonminority applicants is not well established. Thus, this study aimed to fill these knowledge gaps by examining the extent of and factors shaping educational debt among orthopaedic surgery applicants.

QUESTIONS/PURPOSES

(1) What is the educational debt burden among orthopaedic surgery residency applicants? (2) After controlling for relevant confounding variables, what factors are independently associated with increasing levels of educational debt? (3) After controlling for relevant confounding variables, are individuals classified as an underrepresented minority or those with educational debt and socioeconomic disadvantage less likely to match in orthopaedic surgery?

METHODS

A retrospective evaluation of orthopaedic surgery residency application data from the American Association of Medical Colleges was analyzed from 2011 to 2021. The American Association of Medical Colleges database was selected because every residency applicant must register and apply through the American Association of Medical Colleges. Therefore, these data exist for every residency applicant, and the sample was comprehensive. Self-reported data including premedical, medical, and total educational debt burden as well as classification as socioeconomically disadvantaged and application fee waiver use were collected. Applicants were dichotomously categorized as an underrepresented minority or a not underrepresented minority based upon self-identified race and ethnicity. Monetary values were reported in USD and inflation-adjusted to 2021 using the Consumer Price Index. We performed t-tests and chi-square tests for continuous and categorical variables, respectively. Significance was considered at p < 0.05. In all, 12,112 applicants were available in the initial cohort, and 67% (8170 of 12,112) of applicants with complete data were included from 2011 to 2021 in the final study cohort. Of these, 18% (1510 of 8170) were women, 14% (1114 of 8170) were classified as underrepresented minorities, and 8% (643 of 8170) were classified as socioeconomically disadvantaged. Sixty-one percent (4969 of 8170) of applicants reported receiving at least one scholarship, 34% (2746 of 8170) had premedical school debt, and 72% (5909 of 8170) had any educational debt including medical school. Among all applicants, the median (IQR) educational debt was USD 197,000 (25,000 to 288,000). Among those with scholarships, the median amount was USD 25,000 (9000 to 86,000).

RESULTS

After controlling for the potentially confounding variables of gender and socioeconomic disadvantage, classification as an underrepresented minority applicant was independently associated with higher scholarship amounts than applicants characterized as not underrepresented minorities (β = USD 20,908 [95% confidence interval (CI) 15,395 to 26,422]; p < 0.001), whereas underrepresented minority classification was not independently associated with a difference in total educational debt (β = USD 3719 [95% CI -6458 to 13,895]; p = 0.47). After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with higher scholarship amounts (β = USD 20,341 [95% CI 13,300 to 27,382]; p < 0.001) and higher total educational debt (β = USD 66,162 [95% CI 53,318 to 79,006]; p < 0.001) than applicants not classified as socioeconomically disadvantaged. After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with decreased match rates (OR 0.62 [95% CI 0.52 to 0.74]; p < 0.001).

CONCLUSION

These findings underscore the need for comprehensive scholarship initiatives to ensure equitable financial accessibility for applicants from all backgrounds.

CLINICAL RELEVANCE

In the future, orthopaedic surgery may benefit from research comparing the effectiveness of various initiatives aiming to improve fairness in the burden of debt among applicants to orthopaedic surgery residency programs.

Predicting Satisfaction of Parents of Pediatric Patients: Perceived Quality of Providers' Communication Mitigates Negative Effects of Shorter than Desired Consultations

This research investigated the predictors of satisfaction for parents of pediatric patients after a clinical consultation. Specifically, we assessed whether perceptions of their provider's communication quality influenced the degree to which their (dis)satisfaction with consultation length associated with their provider rating and intent to recommend the provider's office. Using patient satisfaction survey data collected after initial clinical visits to a pediatric hospital (N = 12,004), we found that communication quality was a stronger predictor for those who were dissatisfied with their consultation length, whereas communication quality made a relatively smaller difference for those who were satisfied with their consultation length. Put another way, parents' dissatisfaction with their child's consultation length mattered little when they perceived their provider to be high in communication quality, but it reduced their ratings and intentions to recommend when they perceived their provider to be low in communication quality. These results suggest that providers' communication behaviors have the capacity to buffer patients' negative evaluations otherwise incurred from shorter than desired consultations.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes

BACKGROUND

Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.

RESULTS

Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.

CONCLUSION

Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

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.

Racial and Ethnic Disparities in Sports Medicine and the Importance of Diversity

Within orthopedics surgery as a specialty, sports medicine is one of the least diverse surgical subspecialties. Differences in minority representation between patient and provider populations are thought to contribute to disparities in care, access, and outcomes.

Are We Speaking the Same "Language" Regarding Underrepresented Groups in Plastic Surgery and Increasing Diversity Within Our Field?

BACKGROUND

Plastic Surgery is one of the fields that lags behind the rest when it comes to surgeons from backgrounds underrepresented in medicine (URiM). Extensive research has shown that diversity in health care not only fosters inclusivity but also saves lives. The study aim is to quantify how many integrated plastic surgery residency programs have outlined criteria defining diversity goals and/or groups of people they consider to be URiM.

METHODS

All American Council for Graduate Medical Education-accredited integrated plastic surgery program Web sites were reviewed for diversity missions/statements and explicit mentions of the racial and ethnic groups. Web sites were deemed "up-to-date" if they were last updated within 6 months before the initial data collection period. The data collection period was from November 20 to 29, 2022.

RESULTS

A total of 86 program were reviewed. Only 8 programs (9%) had clear URiM criteria listed on their Web sites, whereas 26 (30%) relied on institution/department-wide criteria, 1 (1%) listed that they were adhering to American Association of Medical Colleges definition of URiM, and 51 programs (60%) had no form of definition for what is considered URiM. When looking at the programs that have some form of criteria for URiM (n = 35 [40%]), all programs (100%) considered African American/Black, Native American/Alaskan Native, Hispanic/Latinx, and Pacific Islander/Native Hawaiian as groups URiM. Assessing the same subset of programs that have a form of criteria listed (n = 35 [40%]), 19 (58%) had listed other groups outside of race/ethnicity considered to be URiM for their program, and 14 (42%) programs did not. Fourteen programs (74%) considered LGBTQIA+ as a URiM group.

CONCLUSION AND SIGNIFICANCE

There still is a great deal of heterogeneity among residency programs when it comes to identifying which medical students are URiM. Numerous plastic surgery organizations have placed diversity and inclusive excellence at the forefront of their agendas; however, it is critical that residency programs also actively align their efforts in an equitable and intentional way. This study serves to encourage residency programs to evaluate their mission toward diversity, equity, and inclusion and to spark discussion toward creating a clearer URiM definition to be consistent among all programs.

Racial/Ethnic and Gender Diversity of Orthopaedic Journal Editorial Boards

BACKGROUND

In the current era of evidence-based medicine, scientific publications play a crucial role in guiding patient care. While the lack of diversity among orthopaedic surgeons has been well documented, little is known about the diversity of orthopaedic journal editorial boards. The purpose of this study was to assess the racial/ethnic and gender diversity of U.S. orthopaedic journal editorial boards.

METHODS

The editorial boards of 13 orthopaedic journals were examined, including 10 subspecialty and 3 general orthopaedic journals. Race/ethnicity and gender were determined for each editorial board member. The representation observed on orthopaedic journal editorial boards was compared with representation at other phases of the orthopaedic pipeline, as well as within the various subspecialty fields of orthopaedics. Logistic regression and t tests were used to evaluate these comparisons.

RESULTS

We identified 876 editorial board members of the 13 journals; 14.0% were Asian, 1.9% were Black, 1.9% were Hispanic, 2.4% were multiracial/other, and 79.7% were White. Racial/ethnic representation was similar across the subspecialty fields of orthopaedics (p > 0.05). The representation of women on orthopaedic editorial boards was 7.9%, with differences in gender diversity observed across subspecialty fields (p < 0.05). Among journals in the subspecialty fields of spine and trauma, female editorial board representation was lower than expected, even after taking into account the representation of women in these subspecialty fields (2.0% versus 9.0% [p = 0.002] and 3.8% versus 10.0% [p = 0.03], respectively).

CONCLUSIONS

In this study of 13 subspecialty and general orthopaedic journals, the representation of racial/ethnic minorities and women on editorial boards was similar to their representation in academic orthopaedics. However, these values remain low in comparison with the population of patients treated by orthopaedic surgeons. Given the importance of scientific publications in the current era of evidence-based medicine, orthopaedic journals should continue working to diversify the membership of their editorial boards.

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.

Limb Lengthening and Reconstruction Society orthopedic surgeons in the United States: An analysis of geographical distribution, academic, leadership, and demographic characteristics

BACKGROUND

The Limb Lengthening and Reconstruction Society (LLRS) is a premier orthopedic specialty organization that promotes limb reconstruction for all ages. LLRS membership characteristics, however, are poorly reported. This study delineates orthopedic surgeon LLRS members' demographic traits, academic achievement, leadership attainment, and geographical distribution across the United States.

AIM

To inform aspiring orthopedic professionals, as well as to promote growth and diversity in both the LLRS organization and overarching field.

METHODS

This cross-sectional study examined United States LLRS members' academic, leadership, demographic, and geographical attributes. After reviewing the 2023 LLRS member directory, Google search results were matched to the listings and appended to the compiled data. Sex and ethnicity were evaluated visually utilizing retrieved images. The Hirsch index (H-index) of academic activity, residency and fellowship training, other graduate degrees, leadership positions, practice type (academic or non-academic), and spoken languages were categorized. LLRS members per state and capita determined geographic distribution. The Mann-Whitney U test was applied to compare H-index between males and females, as well as to assess member differences pertaining to affiliation with academic vs non-academic practice facilities.

RESULTS

The study included 101 orthopedic surgeons, 78 (77.23%) Caucasian and 23 (22.77%) non-Caucasian, 79 (78.22%) male and 22 (21.78%) female. Surgeons with DO degrees comprised only 3.96% (4) of the cohort, while the vast majority held MDs [96.04% (97)]. Mean H-index was 10.55, with male surgeons having a significantly higher score (P = 0.002). Most orthopedic surgeons (88.12%,) practiced in academic centers. Of those professionals who occupied leadership positions, 14% were women, while 86% were men. Additionally, 19 (37.25%) United States regions and the District of Columbia lacked an LLRS-member orthopedic surgeon. Total per capita rate across the United States was 0.30 LLRS orthopedic surgeons per 1 million people.

CONCLUSION

Over 21% of LLRS members are women, surpassing prior benchmarks noted in orthopedic faculty reporting. LLRS members' high research productivity scores imply field dedication that can refine expertise in the limb lengthening and reconstruction space. Gender disparities in leadership remain, however, necessitating greater equity efforts. A low rate of LLRS representation per capita must be addressed geographically as well, to affect improvements in regional care access. This study can serve to support aspiring orthopedic professionals, inform diversity, leadership, and field advancement strategies, and maintain the continued goal of enhanced patient care worldwide.

Gender Disparities in Endowed Professorships Within Orthopaedic Surgery

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

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.].

Leadership Trends at Hand Surgery Fellowships

BACKGROUND

Fellowship directors (FDs) influence the future of trainees in the field of hand surgery. Currently, there are no studies that analyze the demographic background, institutional training, and academic experience of hand surgery FDs. This study aims to serve as a framework to understand the landscape of current leadership positions in hand surgery education and to identify opportunities to improve FD diversity.

METHODS

The American Society for Surgery of the Hand Fellowship Directory was reviewed to include all hand surgery fellowships in the United States. Collected demographic information regarding FDs included age, sex, ethnicity, residency/fellowship training, residency/fellowship graduation year, year hired by current institution, time since training completion until FD appointment, length in FD role, and H-index.

RESULTS

Of the 90 FDs included, 86.7% were men and 71.4% self-reported as Caucasian. The average H-index was 13.98 and significantly correlated with age and duration as FD; 71.1% of FDs were trained in orthopedic surgery. The most attended residency program was the University of Pennsylvania; Mayo Clinic and Harvard University were the most represented fellowship programs.

CONCLUSION

This review reveals specific trends in demographic backgrounds, institutional training, and academic experiences among current FDs in hand surgery. Our observations, such as racial/ethnic and sex disparities, may offer opportunities to improve the representation of the communities these physicians serve. In addition, the trends described in this study provide objective data among current hand surgery FDs and could serve as a guide for individuals who desire academic leadership roles.

Diversity in Orthopaedic Sports Medicine Societies

Purpose

The purpose of this study was to report demographic trends in terms of ethnicity/race and gender among the membership and leadership positions of the Arthroscopy Association of North America (AANA) and the American Orthopaedic Society of Sports Medicine (AOSSM). Over the years both AANA and AOSSM will increase in diversity through their committee membership and leadership positions.

Methods

AANA and AOSSM membership and leadership were reviewed for the years 2010, 2015, and 2020. Race/ethnicity was divided into Caucasian, Asian, African American (AA), Hispanic/Latin/South American (HLSA), and Middle Eastern (ME). Gender was limited to male or female, based on name and photographic depiction.

Results

Diversity in AANA and AOSSM committee and leadership positions is summarized in Table 1 and Table 2, respectively. In 2010, 166/191 (87%) AANA committee members were Caucasian, as compared with 125/186 (67%) in 2020. Asian committee members were similar in 2010 (13/191, 7%) and 2015 (13/216, 6%) but increased to 17/186 (10%) in 2020. HLSA committee members increased from 5/191 (3%) 2010 to 11/186 (6%) in 2020. AA committee membership increased from 2/191 (1%) in 2010 to 5/186 (3%) in 2020. The diversity of AANA Board of Director leadership positions increased, with Caucasian representation decreasing from 14/14 (100%) 2010 to 11/12 (92%) in 2020 and Asian representation increasing from 0% in 2010 to 1/12 (8%) in 2020, with HLSA, AA and ME remaining the same with 0/12 (0%). In AANA, men comprised 181/191 (95%) committee members in 2010 and 166/186 (89%) in 2020. The percentage of female committee members increased from 10/191 (5%) in 2010 to 20/186 (11%) in 2020. In 2010, 73/79 (92%) AOSSM committee members were Caucasian compared to 62/81 (77%) in 2020 with AA having the largest increase in committee members from 0% in 2010 to 6/81 (7%) in 2020 (Table 2). Within AOSSM, men comprised 73/79 (92%) committee members in 2010 and 70/81 (86%) in 2020. The percentage of female committee members in AOSSM increased from 6/79 (8%) in 2010 to 11/81 (14%) in 2020.

Conclusion

There has been a progressive trend toward increasing diversity in both committee membership and leadership positions in AANA and AOSSM from 2010 to 2020. Within AANA, there has been a decrease in the Caucasian representation from 87% in 2010 to 67% in 2020 and an increase in the female representation from 5% in 2010 to 11% in 2020. AOSSM demonstrated a similar trend, with Caucasian representation decreasing from 92% in 2010 to 77% in 2020, in addition to female percentage increasing from 8% in 2010 to 14% in 2020. Although there has been an increase in representation of minority and female orthopaedic surgeons within both societies, there is still room for more diversity and inclusion within committee membership and leadership. It is important to progress toward the understanding of the changes that need to be made and work to implement opening the field of orthopaedic sports medicine.

Perceptions of Racial and Gender Microaggressions in an Academic Orthopaedic Department

Orthopaedic surgery consistently ranks last among all medical specialties in diversity and inclusion. While active efforts have recently been implemented to enact change, no study to date has explored the potential effects that social microaggressions have on an individual's career in orthopaedic surgery. The primary aim of this study was to investigate the influence of the perceived experiences of gender and race-based microaggressions on orthopaedic surgery residents, fellows, and attendings in their decision to pursue a career in orthopaedic surgery.

METHODS

A 34-question institutional review board-approved, modified version of the validated Racial and Ethnic Minorities Scale and Daily Life Experiences survey was sent to a total of 84 individuals at the University of Miami (UM) Department of Orthopaedics. Responses were anonymously collected from current UM orthopaedic residents, fellows, and attendings. Survey results were analyzed for the prevalence of microaggressions in the context of sex, race, ethnicity, academic goals, daily scenarios, and department support. p-Values less than 0.05 were considered statistically significant.

RESULTS

Fifty-four of 84 respondents (64%) completed the survey. Female respondents experienced significantly more gender-based microaggressions than male respondents. On average, male participants disagreed that their experiences with microaggressions made them doubt their ability to pursue a career in orthopaedic surgery while female participants responded they were neutral. In comparison with their White counterparts, non-White and Hispanic ethnicity participants demonstrated a statistically significantly greater frequency of race and ethnicity-based microaggressions.

CONCLUSION

Our study demonstrates that female participants, non-White participants, and Hispanic minorities across all levels of training experience a higher frequency of microaggressions. The impact of these experiences on career decisions and goals for women and persons of color in orthopaedic surgery at this single institution is mixed. Experienced microaggressions should be further investigated as a potential barrier to recruitment and retention of under-represented minorities in orthopaedic surgery.

LEVEL OF EVIDENCE

III.

Orthopaedic Surgery Training and Education During COVID-19: A Systematic Review

COVID-19 forced surgical resident training programs to adapt to meet educational requirements within the constraints of various guidelines. Some of the changes implemented during the pandemic have imparted a lasting effect on orthopaedic education. As such, the purpose of this article was to review how orthopaedic training and education were affected during the COVID-19 pandemic.

Methods

The published literature was queried using search strategies devised by a medical librarian, according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Studies eligible for inclusion were studies related to COVID-19, orthopaedic surgical training, and medical education. Studies were excluded if they (1) were abstracts, conference proceedings, letters, perspective pieces, reviews, or editorials; (2) evaluated medical student education; (3) included other specialties; or (4) were unrelated to COVID-19 and/or orthopaedic training.

Results

Eighty-three (n = 83) studies were included. Five themes emerged including (I) Fellowship Application, Interview, and Match Processes; (II) Social Media and Websites for Program Information; (III) Changes in Trainee Surgical Volume; (IV) Trainee Mental Health and Well-being; and (V) Innovations in Education. The pandemic decreased opportunities for medical students to gain exposure to orthopaedic surgery. Social media use, particularly Instagram, among orthopaedic residencies increased during the pandemic. Between the cancellation of away rotations and in-person interviews, applicants saved over $6,000; however, both residency applicants and interviewers preferred in-person interviews. The pandemic led to decreased surgical volume and in-person didactics for trainees, thus relying more on virtual learning. Orthopaedic trainees had mixed feelings regarding online virtual education. Although some respondents reported that they preferred the convenience of online learning, others expressed dissatisfaction with the quality of virtual education.

Conclusions

The shift to virtual learning affected how applicants learned about residency programs, with many relying on virtual away rotations and social media to compare different programs. The pandemic also highlighted issues of diversity and accessibility within orthopaedic surgery, with cost savings from virtual interviews and canceled away rotations potentially benefiting applicants from lower socioeconomic backgrounds. Although some innovative approaches and adaptations to orthopaedic education and training have shown promise and may continue to be used in the future after the COVID-19 pandemic, the role of others, such as virtual interviews, is less clear.

Bias in Surgical Residency Evaluations: A Scoping Review

OBJECTIVE

Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States.

DESIGN

A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively.

SETTING/PARTICIPANTS

English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included.

RESULTS

The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery.

CONCLUSIONS

Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty

BACKGROUND

There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty.

METHODS

A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts.

RESULTS

There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort.

CONCLUSION

SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.

Gender and Racial Diversity Among the Head Medical and Athletic Training Staff of Women's Professional Sports Leagues

Background

Despite increased awareness for promoting diversity, orthopaedics remains one of the least diverse specialties. Studying health care providers in women's professional sports provides a unique opportunity to analyze gender and racial diversity.

Hypotheses

There would be low female and minority representation across the various women's professional sports leagues. There would be an increased number of female head certified athletic trainers (ATCs) when compared with head team physicians (HTPs).

Study Design

Cross-sectional study.

Methods

We evaluated the perceived race and sex of designated HTPs and ATCs in the Women's National Basketball Association, National Women's Soccer League, and National Women's Hockey League. Type of doctorate degree, specialty, and years in practice were also collected. Kappa (κ) coefficient measurements were used to determine interobserver agreement on race. Categorical and continuous variables were analyzed using chi-square and t tests, respectively.

Results

There were significantly more female ATCs than female HTPs (74.1% vs 37.5%; P = .01). Minority representation between HTPs and ATCs was not significantly different (20.8% vs 40.7%; P = .13). Black HTPs (12.5%) and Black ATCs (22.2%) composed the largest proportion among the minority groups. There was high interobserver agreement of perceived race across HTPs (κ = 1.0) and ATCs (κ = 0.95).

Conclusion

Although there were more female ATCs than HTPs in women's professional sports leagues, both cohorts lack perceived racial diversity. These data suggest an opportunity for diversification in medical and training staff of women's professional sports.

Orthopedic Surgery Fellowship Directors: Trends in Demographics, Education, Employment, and Institutional Familiarity

Background: Fellowship directors are assumed to be distinguished in orthopedics, but the traits and training that have enabled them to achieve their leadership positions have not been assessed. Purpose: We sought to identify common demographics, research output, and educational trends of fellowship directors in orthopedics, with an emphasis on racial, ethnic, and gender diversity. Methods: We conducted a literature review to identify published studies on fellowship directors in orthopedic surgery and found 4 cross-sectional studies of fellowship directors in spine, arthroplasty, pediatrics, and sports medicine subspecialties. Another 4 accredited orthopedic subspecialties and their fellowship directors were identified using the American College of Graduate Medical Education Public Accreditation Data System for 2020-2021 and national fellowship directories. Data endpoints included race/ethnicity, age, sex, residency and fellowship training institutions, year of fellowship completion, year of hire at current institution, year of fellowship directors appointment, and h-index. The demographics and educational backgrounds for listed fellowship directors were collected from curricula vitae (CVs). Results: Of the 537 fellowship directors identified among 8 orthopedic subspecialties, the average age was 52.9 ± 2.2 years, 5.6% (N = 30) were women, 79.1% (N = 406) were white, 12.5% (N = 64) were Asian American, 3.7% (N = 19) were African American, 2.9% (N = 15) were Middle Eastern, and 1.7% (N = 9) were Hispanic/Latino. Oncology 20% (N = 4) had the highest percentage of female fellowship directors; 37.6% (N = 202) of fellowship directors were at the same institution they trained at for residency or fellowship. Their average h-index was 18.6 ± 3.7. Conclusion: This study of fellowship directors in orthopedics found that they have a high research output and a high level of institutional familiarity. We identified a need for greater diversity in these leadership positions in both gender and race/ethnicity.

Gender and Racial Bias in Letters of Recommendation for Orthopedic Surgery Residency Positions

OBJECTIVE

The primary purpose of this study was to retrospectively analyze letters of recommendation written for medical students applying to orthopedic residency for implicit race and gender bias. The secondary purpose was to determine if the presence of bias was influenced by the gender of the letter writer.

DESIGN

This was a retrospective institutional review board (IRB) approved study. All letters of recommendation received in the years 2016 to 2018 were deidentified and analyzed using the Linguistics Inquiry and Word Count (LIWC) 2015 software. Independent variables in our analysis were applicant gender and applicant race. Dependent study variables included the summary and characteristic variables of a letter of recommendation, which are word count, analytic, clout, authenticity, tone, and positive and negative emotion word categories. Separate analyses were completed by gender of the letter writer as well.

SETTING

Institution: Temple University Hospital, Philadelphia, Pennsylvania.

PARTICIPANTS

Medical students applying to Temple University Hospital Orthopaedic Surgery Program from 2016 to 2018. A total of 2113 applicants were included in the study.

RESULTS

Female, Asian and underrepresented minority applicants' letters were more likely to have a higher word count. In our subset analysis by gender of letter writer, when the letter writer was male, Asian applicants' letters were more likely to convey analytical thinking and authenticity. When the letter writer was male, male applicants scored higher for authenticity. Letters written by female attendings demonstrated no significant difference for male or female applicants in terms of composite variables or word categories.

CONCLUSIONS

Our study shows that letters of recommendation for orthopedic surgery residency positions are likely to contain some degree of bias. Further studies are required to fully characterize the degree and magnitude of bias in letters of recommendation and whether the findings of our study are significant enough to contribute to the difference in socioeconomic demographics between orthopedic residents and society at large.

Persistent racial discrimination among vascular surgery trainees threatens wellness

OBJECTIVE

Racial/ethnic discrimination is one form of mistreatment and a known risk factor for physician burnout. In the present study, we aimed to characterize the forms and identify the sources of racial/ethnic discrimination among vascular surgery trainees.

METHODS

We performed a cross-sectional study of U.S. vascular surgery trainees who had voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between race and ethnicity groups. We used χ² tests and logistic regression for bivariate and multivariable analyses, respectively.

RESULTS

Representing all 123 vascular surgery training programs, 510 trainees (66.9% men) participated in the survey (83.6% response rate). Most of the trainees had self-identified as White (53.1%), followed by Asian (24.4%), Hispanic/Latinx (7.6%), Black (4.2%), and other/prefer not to say (10.8%). No significant differences were found in the self-reported duty hour violations among the groups. Black (56.3%) and Asian (36.3%) trainees reported higher rates of racial/ethnic discrimination compared with the White, Hispanic/Latinx, and other/prefer not to say groups (P < .001). Patients and their families were reported as the most common source (74.7%). Other reported sources of discrimination included nurses or staff (60%), attendings (37.4%), co-residents (31.3%), and administration (16.9%). Regarding specific forms of racial discrimination, Black and Asian trainees reported the highest rates of different standards of evaluation (20% and 5.9%, respectively), being mistaken for a nonphysician (50.0% and 5.9%, respectively), slurs and/or hurtful comments (13.3% and 5.9%, respectively), social isolation (13.0% and 1.0%, respectively), and being mistaken for another trainee of the same race/ethnicity (60.0% and 33.7%, respectively). Only 62.5% of Black trainees reported their program/institution would take their mistreatment report seriously compared with the White (88.9%), Hispanic/Latinx (88.2%), Asian (83.2%), and other/prefer not to say (71.4%) trainees (P = .01). On multivariable analysis, female gender (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.44-4.33), Asian race (OR, 6.9; 95% CI, 3.53-13.3), Black race (OR, 13.6; 95% CI, 4.25-43.4), and training in the Southeastern United States (OR, 3.8; 95% CI, 1.17-12.80) were risk factors for racial/ethnic discrimination.

CONCLUSIONS

The results from the survey revealed that racial/ethnic discrimination persists in surgical training programs, with Asian and Black trainees reporting higher rates than other racial and ethnic groups. Overall, patients and family members were the most common source of racial/ethnic discrimination. However, faculty, staff, and co-trainees also contributed to racial/ethnic discrimination. Further interventions that optimize diversity, equity, and inclusion strategies and policies to address all forms of racial/ethnic discrimination with faculty, staff, and patients within the hospital are critically needed.

Effective Mentorship of Women and Underrepresented Minorities in Orthopaedic Surgery: A Mixed-Methods Investigation

Orthopaedic surgery is currently the least diverse medical specialty, and there is little research on the mentorship needs for women and underrepresented minorities (URMs) in orthopaedics. The purpose of this study was to examine the roles and functions of mentorship for women and URMs in orthopaedic surgery, to understand mentorship preferences, and to elucidate barriers to mentorship in orthopaedic surgery.

METHODS

Members of J. Robert Gladden Orthopaedic Society and Ruth Jackson Orthopaedic Society were invited to participate. An email with an anonymous link to the survey was distributed; the survey was open for responses from September 2020 through February 2021. The survey contained free-response and quantitative items about mentorship and its impact on current activities, career path, and ways to improve mentorship. Descriptive statistics, 1-way analysis of variance, frequencies, and Fisher exact test were used to analyze survey data. Qualitative data were deidentified and analyzed using thematic analysis techniques.

RESULTS

A total of 155 participants responded to the survey, of those, 151 (98%) met criteria for analysis. Sixty-four percent of participants were women, 15% identified as Black, 4% identified as Hispanic, and 9% identified as multiracial. Eighty-five percent of respondents had a mentor in orthopaedic surgery. Mentorship was often cited as useful for exposure to role models and skills development. Medical students were most likely to consider gender concordance with their mentor important. URM respondents reported greater importance of sharing race/ethnicity with their mentor (p = 0.005). In qualitative responses, participants commented on identity-specific challenges to mentorship, lack of time and institutional support for mentorship, and the disproportionate burden of mentorship on women and URMs.

CONCLUSIONS

Mentorship was highly valued among women and URMs in orthopaedic surgery across all career stages. Mentorship attracted students to orthopaedic surgery and allowed residents and surgeons to progress in the field. Sharing racial/ethnic identity in mentor-mentee relationships was important to both trainees and practicing surgeons.

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.

Impact of considering United States Medical Licensing Examination Step 1 pass/fail on diversity in dermatology residency recruitment

The University of Chicago dermatology residency program considered the United States Medical Licensing Examination (USMLE) Step 1 pass/fail during the 2020-2021 application cycle with the goal of recruiting diverse dermatology residency candidates. We conducted a retrospective multiyear cross-sectional study among applicants to the dermatology residency program during the 2018-2019 and 2020-2021 application cycles, the latter excluding use of USMLE Step 1 cutoff scores as a screening tool. Of the applicants, 69.8% (n = 419) and 94.5% (n = 605) had their residency applications reviewed by our program during the 2018-2019 and 2020-2021 application cycles, respectively. There was a statistically significant upward trend in the number of underrepresented in medicine (URiM) applicants offered an interview from 10.4% (n = 5) to 37.7% (n = 20) across the application cycles. Multiple linear regression demonstrated there was a statistically significant decrease in the mean USMLE Step 1 score among applicants reviewed across application cycle and URiM status independently, and as a factor of their interaction (P = .016 and P = .001). By de-emphasizing the USMLE Step 1 score and using the test as originally intended, a marker for licensure, our program significantly increased the number of URiM applicants who were offered an interview and implemented a holistic review process focused on individual attributes and cultural competence.

Social Determinants of Health Disparities are Associated with Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR).

METHODS

A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR.

RESULTS

58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001).

CONCLUSIONS

The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Race, But Not Gender, Is Associated With Admissions Into Orthopaedic Residency Programs

BACKGROUND

Orthopaedic surgery is one of the most competitive but least diverse surgical specialties, with ever-increasing academic achievements (such as test scores) shown by applicants. Prior research shows that white applicants had higher United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge scores as well as higher odds of Alpha Omega Alpha status compared with Black, Hispanic, and other applicant groups. Yet, it still remains unknown whether differences in application metrics by race/ethnicity sufficiently explain the underrepresentation of certain racial or ethnic minority groups in orthopaedic residency programs.

QUESTIONS/PURPOSES

In this study, we sought to determine (1) the relative weight of academic variables for admission into orthopaedic residency, and (2) whether race and gender are independently associated with admission into an orthopedic residency.

METHODS

The Electronic Residency Application System (ERAS) data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) of first-time MD applicants (n = 8966) for orthopaedic surgery residency positions in the United States and of admitted orthopaedic residents (n = 6218) from 2005 to 2014 were reviewed. This dataset is the first and most comprehensive of its kind to date in orthopaedic surgery. Academic metrics, such as USMLE Step 1 and Step 2 Clinical Knowledge scores, number of publications, Alpha Omega Alpha status, volunteer experiences, work experience, as well as race and gender, were analyzed using hierarchical logistic regression models. The first model analyzed the association of academic metrics with admission into orthopaedic residency. In the second model, we added race and gender and controlled for metrics of academic performance. To determine how well the models simulated the actual admissions data, we computed the receiver operating characteristics (ROC) including the area under curve (AUC), which measures the model's ability to simulate which applicants were admitted or not admitted, with an AUC = 1.0 representing a perfect simulation. The odds ratio and confidence interval of each variable were computed.

RESULTS

When only academic variables were analyzed in the first model, Alpha Omega Alpha status (odds ratio 2.12 [95% CI 1.80 to 2.50]; p < 0.001), the USMLE Step 1 score (OR 1.04 [95% CI 1.03 to 1.04]; p < 0.001), the USMLE Step 2 Clinical Knowledge score (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.001), publication count (OR 1.04 [95% CI 1.03 to 1.05]; p < 0.001), and volunteer experience (OR 1.03 [95% CI 1.01 to 1.04]; p < 0.001) were associated with admissions into orthopaedics while work and research experience were not. This model yielded a good prediction of the results with an AUC of 0.755. The second model, in which the variables of race and gender were added to the academic variables, also had a good prediction of the results with an AUC of 0.759. This model indicates that applicant race, but not gender, is associated with admissions into orthopaedic residency. Applicants from Asian (OR 0.78 [95% CI 0.67 to 0.92]), Black (OR 0.63 [95% CI 0.51 to 0.77], Hispanic (OR 0.48 [95% CI 0.36 to 0.65]), or other race groups (OR 0.65 [95% CI 0.55 to 0.77]) had lower odds of admission into residency compared with white applicants.

CONCLUSION

Minority applicants, but not women, have lower odds of admission into orthopaedic surgery residency, even when accounting for academic performance metrics. Changes in the residency selection processes are needed to eliminate the lower admission probability of qualified minority applicants in orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery. Changes including increasing the diversity of the selection committee, bias training, blinding applications before review, removal of metrics with history of racial disparities from an interviewer's candidate profile before an interview, and use of holistic application review (where an applicants' experiences, attributes, and academic metrics are all considered) can improve the diversity landscape in training. In addition, cultivating an environment of inclusion will be necessary to address these long-standing trends in orthopaedic surgery.

CLINICAL RELEVANCE

Race, but not gender, is associated with the odds of acceptance into orthopaedic surgery residency despite equivalent academic metrics. Changes in residency selection processes are suggested to eliminate the lower admission probability of qualified minority applicants into orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty

BACKGROUND

Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA.

METHODS

We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores.

RESULTS

Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS.

CONCLUSION

Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

Analysis of Current Orthopedic Surgery Residents and Their Prior Medical Education: Does Medical School Ranking Matter in Orthopedic Surgery Match?

OBJECTIVE

The purpose of this study was to determine the strength of the association between medical school ranking and orthopedic surgery residency ranking using the current cohort of orthopedic surgery residents.

DESIGN

We obtained a list of accredited programs from Doximity for orthopedic surgery residency programs and U.S. News & World Report for medical schools. Each orthopedic surgery residency program webpage was evaluated for the presence of an orthopedic surgery residency roster. For each resident, the medical school attended, allopathic or osteopathic degree, and year of post-graduate training was recorded. Orthopedic surgery residency programs and medical schools were assigned to one of four tiers for each based on their respective ranking. Descriptive statistics, Chi squared tests and Pearson residuals were used to analyze the association of orthopedic surgery residency tier and medical school tier. Post-hoc pairwise comparisons were performed utilizing the Bonferroni correction to account for 16 tests, correcting the significance level to p = 0.003.

SETTING

187 orthopedic surgery residency program webpages.

PARTICIPANTS

4123 orthopedic surgery residents.

RESULTS

There was a significant association between medical school tier and orthopedic surgery residency tier (X² [9] = 1214.78, p < 0.001). The post-hoc residual values were statistically significant for 75% (12/16) of tests performed. The majority of Tier 1 orthopedic surgery residents 50.5% (800/1585) attended a Tier 1 medical school. The strongest positive association exists between Tier 1 medical students attending Tier 1 residencies (residual = 23.978, p < 0.001). The strongest negative association with Tier 4 residencies was with Tier 1 medical schools (residual= -15.656, p< 0.001).

CONCLUSIONS

Medical school ranking is an important consideration for prospective orthopedic surgery applicants and may become more important with less objective measures of academic performance such as United States Medical Licensing Examination Step 1.

LEVEL OF EVIDENCE

Observational.

National Evaluation of Social Determinants of Health in Orthopedic Fracture Care: Decreased Social Determinants of Health Is Associated With Increased Adverse Complications After Surgery

OBJECTIVES

To assess the individual impact of social determinants of health disparities (SDHD) on surgical outcomes following orthopaedic trauma surgery.

DESIGN

Retrospective Cohort Study.

SETTING

Mariner Claims Database.

PATIENTS

Inclusion criteria were patients 18-85 years of age, undergoing surgery for hip fractures or ankle fractures from 2010 to 2018.

INTERVENTION

Patients were divided based on SDHD using International Classification of Diseases 9 and International Classification of Diseases 10 codes. Those with SDHD were propensity-score matched with those who did not have any disparities with respect to age, gender, Charlson comorbidity index, tobacco use, and obesity (body mass index >30 kg/m2).

OUTCOMES

Ninety-day major medical complications, infection, readmission, and revisions within 1 year.

RESULTS

Patients with educational deficiencies had increased rates of readmission and major complications compared with those without disparities following hip and ankle fracture management. Moreover, economic disparities were associated with an increased risk of readmission and revision following hip fracture surgery and infection and readmission following ankle fracture surgery.

DISCUSSION/CONCLUSIONS

This study emphasizes the large impact of SDHD on patients' outcomes following surgery and the importance of proper follow-up interventions to optimize patient care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

COVID-19 Increased Residency Applications and How Virtual Interviews Impacted Applicants

Background

The number of residency applications submitted by medical students has risen at an alarming rate, causing increased cost of applications and subsequent interview travel. These both contribute to increased cost for medical students. In light of these concerns, specialty governing bodies have proposed ideas to fight these trends including, application limits, interview limits, using a preference signaling system, and continuing virtual interviews. During the Covid-19 pandemic, all residency interviews were performed virtually, essentially making travel expenses negligible. However, this created a new concern with regards to assessing program and applicant compatibility, as compared to in-person interactions and did nothing to combat the increases in application numbers. Therefore, we want to critically assess the effects of virtual interviews on number of applications submitted, number of interview invites received, and number of interviews attended. We also aim to analyze how applicants viewed the virtual process.

Methods

600 medical students were eligible to participate. 456 students from years 2018-2020 were eligible to be surveyed following the NRMP match. 144 students were eligible to be surveyed following 2021 NRMP match. The survey was distributed to medical school graduates just prior to graduation and asked how many programs each student applied to, how many interview invites they received, and how many interviews they attended. The 2021 survey also asked, “How did virtual interviews affect your interview experience?” The quantitative results were compared with student's t-test and qualitative results are presented below. 

Results

The average number of programs each applicant applied to increased from 35.4 to 47.7 (p-value=0.002) when residency interviews switched from in-person to virtual. However, interview invites received and interviews attended did not change (16.8 vs 16.3, p-value=0.91, 11.8 vs 12.7, p-value=0.18). There were 188 participants in the in-person interview group (response rate=41.2%) and 128 participants in the virtual interview group (response rate=83.3%). The standard deviation and range also increased for number of applications, number of interview invites received, and number of interviews attended. 

There were 123 responses to the free response question. 36 had a positive experience, 44 were neutral, 47 were negative. The positive themes included 15 noted less expenses, 18 noted more convenient/less time, and 18 were able to attend more interviews. Negative themes included, 38 noted difficulty assessing program fit, 19 wanted to see the program or city in person, eight had increased interest in home/local programs, six found it difficult to make connections or stand out. 

Conclusion

Sixty-three percent of students reported a positive or neutral experience with virtual interviews. Students applied to more programs when interviews were virtual, but did not receive more interview invites or attend more interviews. These results suggest that virtual interviews are sufficient to conduct residency interviews, however the number of applications continues to rise with no increase in the number interview invites received or number of interviews attended. The increase in the standard deviation and range for all three variables may point to some applicants being able to get more invites and attend more interviews leaving less available spots for other applicants. 

Investigation of Fellowship Leadership in Orthopaedic Musculoskeletal Oncology

Introduction:

Methods:

Results:

Conclusion:

A track record of diversity: Medical schools ranked by successful black applicants to orthopaedic residencies

BACKGROUND

Orthopaedic surgery is the least diverse surgical subspecialty in medicine. However, to date, there is no literature that shows which medical schools have successfully contributed to improving orthopaedic surgeon diversity.

OBJECTIVE

The purpose of this study is to identify the top U.S. medical schools that have successfully matched black applicants into orthopaedic surgery residencies and juxtapose this ranking to the current top medical schools as ranked by the U.S. News and World Report (USNWR).

METHODS

The J. Robert Gladden Orthopaedic Society (JRGOS) database was queried for all orthopaedic surgeons, fellows, and residents who identified as black or multi-racial with black being one of the included races, yielding 938 physicians, of which 672 met our inclusion criteria. From this list, a ranking of the top 20 medical schools was generated.

RESULTS

The top five medical schools ranked in the JRGOS database are Howard University College of Medicine (HUCOM), Meharry Medical College, Harvard Medical School (HMS), the University of Pennsylvania, and Morehouse School of Medicine (MSM). In addition, 10 (50%) of the medical schools ranked in the top 20 by the JRGOS database were also ranked by the USNWR. When ranking medical schools for black female applicants, HUCOM, MSM, HMS are the top three programs. Lastly, a ranking by region identified that the northeast contained the highest number of ranked medical schools.

CONCLUSION

There are both historically black and non-historically black medical schools which have a proven track record of producing a significant number of future black orthopaedic surgery residents.

Trends in leadership at shoulder and elbow fellowships: a cross-sectional demographic review

OBJECTIVE

To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs).

BACKGROUND

Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery.

METHODS

Using the American Shoulder and Elbow Surgeons (ASES) directory website page "ASES-Recognized Shoulder and Elbow Fellowship Programs," we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled data points include age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history.

RESULTS

We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. The majority of FLs (97.5%) were male whereas 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n = 2). The top fellowship programs for producing future FLs were Mayo Clinic (n = 6), Columbia University (n = 6), San Francisco/California Pacific (n = 4), and Washington University in St Louis (n = 4).

CONCLUSION

Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity; however, demographic diversity remains limited, which is comparable to prior orthopedic subspecialty FL investigations.

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.

Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States

As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities.

Academic, Leadership, and Demographic Characteristics of Orthopaedic Sports Medicine Division Chiefs in the United States

Introduction:

Division chiefs (DCs) play an integral role within the department, making critical decisions and helping shape the future of both the division and the department. This study aimed to investigate the demographic characteristics and scholarly work of DCs in academic orthopaedic sports medicine division in the United States.

Methods:

Orthopaedic residency programs at academic centers were identified using the Association of American Medical Colleges' Electronic Residency Application Service. DCs were identified using the program's respective websites where data points such as sex, race/ethnicity, fellowship training institution, time since graduating fellowship, academic rank, number of degrees, and additional leadership titles were collected. Scopus database was used to determine h-indices.

Results:

From the 191 programs identified, 100 had a DC for the sports medicine subspecialty division, and 66 programs offered a sports medicine fellowship. Most DCs (96%) were men. The racial/ethnic demographics of the DCs were mostly White (86%), followed by Asian (11%), African American (1%), Hispanic/Latino (1%), and mixed ethnicity (1%). On average, the DCs were 19.6 years past their fellowship completion. The average h-index was 21.2. Many (48%) had an academic rank of professor, 28% associate professor, and 12% assistant professor. Four held additional graduate degrees. The fellowship programs that trained the most DCs were Hospital for Special Surgery (11), Kerlan Jobe Orthopaedic Clinic (8), University of Pittsburgh (7), American Sports Medicine Institution (5), Cleveland Clinic (5), Cincinnati Sports Medicine (4), Massachusetts General Hospital (4), and Steadman Hawkins Clinic (4).

Discussion:

DCs in academic orthopaedic surgery plays a crucial role in the department and is a topic that is understudied. A lack of diversity exists among DCs in academic Sports Medicine in orthopaedics. The position is held predominately by White men with a rank of either full or associate professor and extensive leadership experience. More efforts are needed to increase the diversity of sports medicine leadership within academic orthopaedic programs in the United States.

Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review

BACKGROUND

Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement.

METHODS

We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES).

RESULTS

Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric.

CONCLUSIONS

This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.

Effect of the COVID-19 Pandemic on the Orthopaedic Surgery Residency Application Process: What Can We Learn?

INTRODUCTION

The goal of this study was to assess the influence of the coronavirus disease 2019 pandemic on the orthopaedic surgery residency application process in the 2020 to 2021 application cycle.

METHODS

A survey was administered to the program directors of 152 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs. The following questions were assessed: virtual rotations, open houses/meet and greet events, social media, the selection criteria of applicants, the number of applications received by programs, and the number of interviews offered by programs.

RESULTS

Seventy-eight (51%) orthopaedic residency programs responded to the survey. Of those, 25 (32%) offered a virtual away rotation, and 57 (75%) held virtual open houses or meet and greet events. Thirteen of these programs (52%) reported virtual rotations as either "extremely important" or "very important." A 355% increase was observed in social media utilization by residency programs between the 2019 to 2020 and 2020 to 2021 application cycles, with more programs finding social media to be "extremely helpful" or "very helpful" for recruiting applicants in 2020 to 2021 compared with the previous year (39% versus 10%, P < 0.001).

CONCLUSION

Although many of the changes seen in the 2020 to 2021 application cycle were implemented by necessity, some of these changes were beneficial and may continue to be used in future application cycles.

Current Perceptions of Diversity Among Head Team Physicians and Head Athletic Trainers: Results Across US Professional Sports Leagues

BACKGROUND

Discrepancies in race, ethnicity, and sex among health care providers and their patients have been shown to affect the patient-provider relationship as well as the quality of care. Currently, minority and female representation among orthopaedic surgeons remains low. Given the large proportion of minority athletes and their degree of public visibility, professional sports serves as an important arena within which to analyze the diversity of health care providers.

PURPOSE

To describe and evaluate the current level of diversity of head team physicians (HTPs) and head athletic trainers (ATCs), primarily in terms of race and sex, within men's professional sports leagues in the United States.

STUDY DESIGN

Cross-sectional study.

METHODS

Five major US professional sports leagues were evaluated: National Basketball Association, National Football League, National Hockey League, Major League Soccer, and Major League Baseball. Publicly available data were collected to identify the HTPs and head ATCs for each team within these leagues. Two independent observers analyzed photographs and names of these individuals to determine his or her perceived race and sex, with disagreements being resolved by a third independent observer. Other physician data collected included graduate degree(s), specialty, and number of years in practice. Kappa coefficients (κ) were employed to evaluate interobserver reliability. Chi-square, Fisher exact, and t tests were used for statistical comparisons across leagues.

RESULTS

The κ values for perceived race were 0.85 for HTPs and 0.89 for head ATCs, representing near-perfect interobserver agreement. Minorities comprised 15.5% of HTPs and 20.7% of ATCs (P = .24). Women comprised 3.9% of HTPs and 1.3% of head ATCs (P = .017). The majority of HTPs were orthopaedic surgeons with medical doctorates. Female HTPs had significantly fewer years in practice compared with male HTPs (15.0 ± 4.9 vs 23.1 ± 9.6; P = .04).

CONCLUSION

The lead physicians and athletic training providers for men's professional sports teams demonstrated low rates of minority and female representation, denoting a highly visible area for discussing the role of increased diversity in health care.

Objective Test Scores Throughout Orthopedic Surgery Residency Suggest Disparities in Training Experience

Diversifying clinical residencies, particularly in fields that are historically dominated by majority male (M/M) cohorts, is critical to improve both the training experiences of residents and the overall physician workforce. Orthopedic surgery in particular has low numbers of females and under-represented minorities (F/URM) at all levels of training and practice. Despite efforts to increase its diversity, this field has become more homogeneous in recent years. To highlight potential barriers and disparate training environments that may contribute to this dynamic, we present 25 years' worth of institutional data on standardized exam performance throughout residency. We report that despite starting residency with standardized exam scores that were comparable to their M/M peers, F/URM orthopedic surgery residents performed progressively worse on Orthopaedic In-service Training Exams throughout residency and had lower first pass rates on the American Board of Orthopedic Surgery Part 1. Given these findings, we propose that disparate performance on standardized test scores throughout residency could identify trainees that may have different experiences that negatively impact their exam performance. Shedding light on these underlying disparities provides opportunities to find meaningful and sustained ways to develop a culture of diversity and inclusion. It may also allow for other programs to identify similar patterns within their training programs. Overall, we propose monitoring test performance on standardized exams throughout orthopedic surgery residency to identify potential disparities in training experience; further, we acknowledge that interventions to mitigate these disparities require a broad, systems wide approach and a firm institutional commitment to reducing bias and working toward sustainable change.

The Impact of Race and Socioeconomic Status on Total Joint Arthroplasty Care

BACKGROUND

Racial minorities and patients from lower socioeconomic backgrounds are less likely to undergo total joint arthroplasty (TJA) for degenerative joint disease (DJD). However, when these patients do present for care, little is known about the overall severity of DJD and surgical wait times.

METHODS

A retrospective cohort of 407 patients (131 black and 276 white) who presented to an arthroplasty clinic and went on to receive TJA was established. Severity of osteoarthritis was assessed radiographically via Kellgren-Lawrence (KL) grade. Preoperative Knee Society Score (KSS) and Harris Hip Score (HHS) were used to measure joint pain and function. Multivariate regression modeling and analysis of covariance were used to examine racial and socioeconomic differences in KL grade, KSS, HHS, and time to surgery.

RESULTS

Black patients presented with significantly greater KL scores than white patients (P = .046, odds ratio = 1.65, 95% confidence interval [1.01, 2.70]). In contrast, there were no statistically significant racial differences in the mean preoperative KSS (P = .61) or HHS (P = .69). Black patients were also found to wait, on average, 35% longer for TJA (P = .03, hazard ratio = 1.35, 95% confidence interval [1.04, 1.75]). Low income was associated with higher KL grade (P = .002), lower KSS (P = .07), and lower HHS (P = .001).

CONCLUSION

Despite presenting with more advanced osteoarthritis, black patients reported similar levels of joint dysfunction and had longer surgical wait times when compared with white patients. Lower socioeconomic status was similarly associated with more severe DJD.

How to Be An Antiracist Hand Surgery Educator

Racism that unjustly marginalizes black people in the United States is not a new concept. It underlies nearly every aspect of American history, leading to the systemic racism that is ingrained in our society today. With the recurrent theme of people of color having worse health outcomes than the majority community, it is important for hand surgeons to employ cultural competence and antiracist education to provide better care and support for patients, staff, students, and colleagues. In this article, we will provide a definitional framework, clinical examples, and practical pearls to promote change. To reduce racial and ethnic health care inequities and diversify the field of hand surgery, we must advocate on behalf of black and brown colleagues, staff, students, and/or friends to address racist policies and procedures.