Do women experience microaggressions in orthopaedic surgery? Current state and future directions from a survey of women orthopaedists

Prevalence of Workplace Microaggressions and Racial Discrimination: A Systematic Review and Meta-analysis

Background

In recent years, the rise of workplace racial discrimination and microaggressions has decreased the efficiency and productivity of organizations and institutions, and realization of organizational goals globally. Accordingly, it was decided to conduct a systematic review and meta-analysis in the present study with the aim of investigating the prevalence of microaggression and racial discrimination in the workplace.

Methods

The PubMed, Scopus, Web of Science, ScienceDirect and Google Scholar databases were systematically searched for studies that had reported the effects of work stress among managers. The search did include a lower time limit and was conducted in June 2023. The heterogeneity of the studies was investigated using the I 2 index, and accordingly random effects method was adopted for meta-analysis. Data analysis was conducted with the Comprehensive Meta-Analysis (v.2) software.

Results

In the review of seven studies with a sample size of 2998 people, the overall prevalence of microaggression and racial discrimination in the workplace was found to be 73.6% and 18.8%, respectively. Publication bias within the selected studies was examined with the Egger's test, which indicated the absence of publication bias for the pooled prevalence of workplace microaggression (p: 0.264) and for the pooled prevalence of workplace racial discrimination (p: 0.061).

Conclusion

The results obtained from this report indicate the high impact of micro-aggression and racial discrimination in the workplace. Considering the negative effects of such behaviours, the findings from this study will be helpful to managers and health policymakers.

Strengthening the Pipeline: Promoting Diversity into Orthopedic Surgery

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

Health Considerations for Female Orthopaedic Surgeons

The number of female orthopaedic surgeons is increasing. They face unique health concerns, which include cancer risk, pregnancy and fertility problems, musculoskeletal issues, and mental health disorders. In 2010, a survey study showed a 2.9-fold increased prevalence of breast cancer in female orthopaedic surgeons, compared with women in the general US population. A follow-up study 13 years later showed a 3.97-fold higher prevalence of breast cancer in female orthopaedic surgeons compared with matched women in the US general population. Surveys on fertility have also reported that orthopaedic surgery is one of three surgical subspecialty fields with the highest rates of fertility difficulty. In addition, the rate of pregnancy loss in female surgeons was twice the rate compared with that of the general population. There is an increased risk of preterm delivery in female orthopaedic surgeons. Awareness, education, and preventive measures may help reduce these issues and thereby promote the recruitment, retainment, and success of female surgeons in orthopaedic surgery.

Gender-Related Microaggressions in Orthopedic Surgery: A Comprehensive Survey of Women Orthopedists and Implications for Progress, Saudi Arabia

Background

Microaggressions are subtle and often unintentional acts that can be verbal, nonverbal, or environmental, and they convey negative messages to individuals belonging to marginalized social groups. This study aims to determine the prevalence of microaggressions experienced by female Saudi orthopaedic surgeons.

Methods

This cross-sectional study was conducted online and targeted female in orthopedic surgery across different regions of the Kingdom of Saudi Arabia. The survey was uploaded to Google Forms and distributed through social media platforms like Twitter, Instagram, and WhatsApp by well-trained data collectors.

Results

In this survey we included 96 female Saudi orthopedics. Their mean age was 27.46 ± 12.20 years. Most respondents were either residents (52.63%), or specialists (23.16%). Most participants (92.63%) were still in training or early in their careers, with the vast majority (93.68%) had their residency in Saudi Arabia. Nearly three-fifths (61.05%) have reported experiencing microaggressions as victims, 76.84%, did not see themselves as perpetrators of microaggressions, 23.16% acknowledged having engaged in such behavior. Patients or their families were reported to be involved in microaggressions in 43.16% of cases, while male surgeons and male support staff were implicated at 51.58% and 23.16%, respectively. Additionally, other male medical doctors participate in microaggressions in 33.68% of instances. Female surgeons were identified as being involved in 22.11% of microaggressions, whereas 29.47% involve female support staff.

Conclusion

The study's outcomes can help inform strategies to promote a supportive and inclusive environment within the field of orthopaedic surgery, encouraging positive interactions and equitable opportunities for all practitioners.

Challenges for Women in Hand Surgery: Our Perspective

Over recent decades, the prevalence of women in surgical subspecialties has increased. There has been a significant rise in the percentage of women entering integrated plastic surgery programs and an increase, albeit smaller, in women entering orthopedic surgery training programs. Although female membership in the American Society for Surgery of the Hand has steadily increased, women remain in the vast minority within this professional society and many others within the field of hand surgery. In addition to underrepresentation in positions of leadership, women face challenges such as imposter syndrome, bullying, unfavorable work structure for work-family balance, macro and micro-aggressions, and lack of mentors at a higher rate than their male colleagues. As awareness rises of the additional challenges that women in hand surgery face, we must directly address them to improve equity within our subspecialty.

The Majority of Black Orthopaedic Surgeons Report Experiencing Racial Microaggressions During Their Residency Training

BACKGROUND

Orthopaedic surgery is the least-diverse surgical specialty based on race and ethnicity. To our knowledge, the impact of this lack of diversity on discriminatory or noninclusive experiences perceived by Black orthopaedic surgeons during their residency training has never been evaluated. Racial microaggressions were first defined in the 1970s as "subtle verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group." Although the term "microaggression" has long been established, more recently, as more workplaces aim to improve diversity, equity, and inclusion, it has entered the medical profession's lexicon as a means of describing the spectrum of racial discrimination, bias, and exclusion in the healthcare environment.

QUESTION/PURPOSES

(1) What is the extent of discrimination that is perceived by Black orthopaedic surgeons during residency? (2) What subtypes of racial microaggressions (which encompasses racial discrimination, bias, and exclusion) do Black orthopaedic surgeons experience during residency training, and who are the most common initiators of these microaggressions? (3) What feedback statements could be perceived as racially biased to Black orthopaedic surgeons in residency training? (4) Are there gender differences in the reported types of racial microaggressions recalled by Black respondents during residency training?

METHODS

An anonymous survey was administered between July 1, 2020, and September 1, 2020, to practicing orthopaedic surgeons, residents, and fellows in the J. Robert Gladden Orthopaedic Society database who self-identify as Black. There were 455 Black orthopaedic surgeons in practice and 140 Black orthopaedic residents or fellows in the database who met these criteria. Fifty-two percent (310 of 595) of participants responded. Fifty-three percent (243 of 455) were practicing surgeons and 48% (67 of 140) were current residents or fellows. Respondents reported their perception of discrimination in the residency workplace using a modified version of the single-item Perceived Occupational Discrimination Scale and were asked to recall any specific examples of experiences with racial discrimination, bias, or exclusion during their training. Examples were later categorized as different subtypes of racial microaggressions and were quantified through a descriptive analysis and compared by gender.

RESULTS

Among survey respondents, 34% (106 of 310) perceived a lot of residency workplace discrimination, 44% (137 of 310) perceived some residency workplace discrimination, 18% (55 of 310) perceived a little residency workplace discrimination, and 4% (12 of 310) perceived no residency workplace discrimination. Categorized examples of racial microaggressions experienced in residency were commonly reported, including being confused for a nonphysician medical staff (nurse or physician's assistant) by 87% (271 of 310) of respondents or nonmedical staff (janitorial or dietary services) by 81% (250 of 310) of respondents. Racially explicit statements received during residency training were reported by 61% (190 of 310) of respondents. Thirty-eight percent (117 of 310) of such statements were reportedly made by patients and 18% (55 of 310) were reportedly made by attending faculty. Fifty percent (155 of 310) of respondents reported receiving at least one of nine potentially exclusionary or devaluing feedback statements during their residency training. Among those respondents, 87% (135 of 155) perceived at least one of the statements to be racially biased in its context. The three feedback statements that, when received, were most frequently perceived as racially biased in their context was that the respondent "matched at their program to fulfill a diversity quota" (94% [34 of 36]), the respondent was unfriendly compared with their peers (92% [24 of 26]), or that the respondent was "intimidating or makes those around him/her uncomfortable" (88% [51 of 58]). When compared by gender, Black women more frequently reported being mistaken for janitors and dietary services at 97% (63 of 65), compared with Black men at 77% (187 of 244; p < 0.01). In addition, Black women more frequently reported being mistaken as nurses or physician assistants (100% [65 of 65]) than Black men did (84% [205 of 244]) during orthopaedic residency training (p < 0.01). Black women also more frequently reported receiving potentially devaluing or exclusionary feedback statements during residency training.

CONCLUSION

Perception of workplace discrimination during orthopaedic residency training is high (96%) among Black orthopaedic surgeons in the United States. Most respondents reported experiencing discrimination, bias, and exclusion that could be categorized as specific subtypes of racial microaggressions. Several different examples of racial microaggressions were more commonly reported by Black women. Certain feedback statements were frequently perceived as racially biased by recipients.

CLINICAL RELEVANCE

To better understand barriers to the successful recruitment and retention of Black physicians in orthopaedics, the extent of racial discrimination, bias, and exclusion in residency training must be quantified. This study demonstrates that racial discrimination, bias, and exclusion during residency, wholly categorized as racial microaggressions, are frequently recalled by Black orthopaedic surgeons. A better understanding of the context of these experiences of Black trainees is a necessary starting point for the development of a more inclusive workplace training environment in orthopaedic surgery.

Interpersonal Interactions and Biases in Orthopaedic Surgery Residency: Do Experiences Differ Based on Gender?

BACKGROUND

Women residents are underrepresented in orthopaedic surgery. The causes of the deficit of women in orthopaedic surgery are multifactorial, but by identifying the perceptions of women in orthopaedic residency training and comparing them with the perceptions of men, we can improve our understanding of ways to enhance the recruitment of qualified and diverse candidates.

QUESTIONS/PURPOSES

(1) What differences exist in the perceived experiences of residents identifying as women and men regarding professional, social, and personal interactions during residency training? (2) Are there differences in the percentage of women and men residents who have experienced harassment or discrimination in preresidency interviews, and are there differences in the type of harassment or discrimination experienced?

METHODS

A survey was generated using Academy of Critical Care: Development, Evaluation, and Methodology guidelines. Two focus groups with seven attending orthopaedic surgeons who participate in the Collaborative Orthopaedic Education Research Group and who are experts on gender diversity in orthopaedics were held to improve survey validity. The survey included binary-response, Likert, and free-text questions on the perception of professional, social, and personal interactions held by the resident being surveyed. The questions focused on a respondent's perception of interactions with staff members, patients, resident colleagues, and attending surgeons, as well as sexual harassment. Program directors at 10 selected Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic residency programs that participate in the Collaborative Orthopaedic Education Research Group shared the survey with residents at their institutions. There were 95 programs in the Collaborative Orthopaedic Education Research Group at the time this survey was distributed. In this program, directors or other interested teaching faculty in orthopaedic residency programs voluntarily participate to discuss and develop quality research on resident and fellow education. These 95 programs account for 46% of the ACGME-accredited programs in the United States at the time the survey was created and distributed. The 10 residency programs had a total of 232 enrolled residents; 15% (34) identified as women. This gender distribution models the national sample of orthopaedic residents. Survey reliability was assessed by calculating the Cronbach alpha after determining the variance in each relevant (nondemographic) survey item. The final survey was found to have excellent internal reliability (alpha = 0.95). Responses from residents identifying as women and those identifying as men were compared using Fisher exact tests for all categorical data, and two-tailed independent t-tests were used for all continuous data. Differences in each survey category (professional interactions, social interactions, personal interactions, and sexual harassment in preresidency interview experiences) were calculated.

RESULTS

Women reported experiencing microaggressions (left undefined to the survey respondent, but generally considered to be subtle, stunning, often automatic, and nonverbal exchanges that are "put downs") at work more frequently than men did (40% [six of 15] versus 5% [four of 74]; p < 0.001). Specifically, women perceived being interrupted (53% [eight of 15] versus 5% [four of 75]); p < 0.001) by men colleagues, called by their first name (67% [10 of 15] versus 4% [3 of 72]; p < 0.001), and given administrative tasks (27% [four of 15] versus 1% [one of 75]; p = 0.004) more often than men. More women than men perceived that patients (33% [five of 15] versus 0 of 74 [0%]; p < 0.001) and hospital staff (27% [four of 15] versus 7% [five of 74]; p = 0.01) respected their opinion less than that of men. More women than men perceived that group humor negatively targeted their gender (47% [seven of 15] versus 1% [one of 75]; p < 0.001) and that criticism of their surgical skill was based on their gender rather than their ability (33% [five of 15] versus 5% [four of 78]; p = 0.005). In residency or subinternship interviews, 20% of women reported experiencing sexual harassment as defined by a listing of known types of harassment in the question stem, compared with 0% of men (p = 0.004). Women reported harassment in the form of verbal remarks of a sexual nature and obscene images in the workplace, whereas men did not report any form of harassment during interviews.

CONCLUSION

These findings suggest that the greatest discrepancies in the perceived experiences of women and men residents lie in professional interactions, and women residents are more likely to experience sexual harassment and disparaging humor than men residents.

CLINICAL RELEVANCE

Addressing these discrepancies, particularly in the professional setting, will help to create a more inclusive work environment and attract more women to orthopaedic surgery. Annual distribution of the survey used in this study by program directors to residents in their programs can help to identify discrepant perceptions that, coupled with the collection of objective data, can be targeted for improvement.

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

Background

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

Methods

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

Results

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

Conclusion

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

An investigation into gender bias in the evaluation of orthopedic trainee arthroscopic skills

BACKGROUND

Women surgeons receive lower compensation, hold fewer academic positions, and hold fewer leadership positions than men, particularly in orthopedic surgery. Gender bias at the trainee level has been demonstrated in various surgical subspecialties, but there is a lack of information on gender bias within the orthopedic training environment. This study investigated whether implicit gender bias is present in the subjective evaluation of orthopedic trainee arthroscopic skills.

METHODS

After institutional review board approval, a web-based survey was sent to American Shoulder and Elbow Surgeons (ASES) members via the society's email listserve. Study participants were informed that the study was being done to develop a systematic evaluation method for trainees. The survey randomized participants to view and evaluate a prefellowship and a postfellowship video of "Rachel" (she/her) or "Charles" (he/him) performing a 15-point diagnostic shoulder arthroscopy. The videos for Rachel and Charles were identical except for the pronouns used in the video. Participants evaluated the trainee's skill level using questions from the Arthroscopic Surgical Skill Evaluation Tool (ASSET). Blinded and deidentified additional comments regarding the trainee's skill were classified as positive, negative, or neutral. Statistical analyses were used to compare scores and comments between Rachel and Charles.

RESULTS

Of 1115 active ASES members, 181 ASES members started the survey and 106 watched both videos and were included in the analysis. Of the 106 participants completing the survey, 96 (91%) were men and 10 (9%) were women with a median (interquartile range) age of 44 (38-51). A teaching role was reported by 84 of 106 participants (79%). There was no significant difference between prefellowship scores (P = .87) or between postfellowship scores (P = .84) for the woman and man fellow. The numbers of comments classified as positive, negative, or neutral were not significantly different between the man and woman fellow (P = .19). Participants in teaching roles gave significantly lower scores to both fellows at both time points (P = .04), and participants who had fellow trainees were more likely to give negative comments to both fellows (P = .02).

DISCUSSION

Trainee gender did not influence the ratings and comments participants gave for trainee arthroscopic skills, suggesting that gender bias may not play a major role in the evaluation of arthroscopic skill during orthopedic training.

#SpeakUpOrtho: Narratives of Women in Orthopaedic Surgery-Invited Manuscript

Microaggressions, bullying, harassment, sexual harassment, and discrimination continue to be experienced by orthopaedic physicians in the workplace. Oftentimes, these behaviors go unreported because of fear of retaliation, and many perpetrators are not held accountable. This article provides examples of stories anonymously submitted to #SpeakUpOrtho on the topics of microaggressions, bullying/harassment, sexual harassment, discrimination, and retaliation by orthopaedic surgery residents, fellows, and attending surgeons. Commentary by experts in the field is also included to provide ways to manage and prevent the perpetuation of these behaviors.

Perception of Racial and Intersectional Discrimination in the Workplace Is High Among Black Orthopaedic Surgeons: Results of a Survey of 274 Black Orthopaedic Surgeons in Practice

INTRODUCTION

There are approximately 573 practicing Black orthopaedic surgeons in the United States, which represents 1.9% overall. The purpose of this study was to describe this underrepresented cohort within the field of orthopaedic surgery and to report their perception of occupational opportunity and workplace discrimination.

METHODS

An anonymous survey was administered to 455 practicing orthopaedic surgeons who self-identify as Black. The 38-question electronic survey requested demographic and practice information and solicited perspectives on race and racial discrimination in current orthopaedic practices and general views regarding occupational opportunity and discrimination.

RESULTS

The survey was completed by 274 Black orthopaedic surgeons (60%). Over 97% of respondents believe that Black orthopaedic surgeons in the United States face workplace discrimination. Most Black orthopaedic surgeons (94%) agreed that racial discrimination in the workplace is a problem but less than 20% agreed that the leaders of national orthopaedic organizations are trying sincerely to end it. Black female orthopaedic surgeons reported lower occupational opportunity and higher discrimination than Black male orthopaedic surgeons across all survey items.

DISCUSSION

This study is the first to report on the workplace environment and the extent of discrimination experienced by Black surgeons, specifically Black orthopaedic surgeons in the United States. Most respondents, particularly female respondents, agreed that racial discrimination and diminished occupational opportunity are pervasive in the workplace and reported experiencing various racial microaggressions in practice.

Assessing the Prevalence of Microaggressions in Plastic Surgery Training: A National Survey

There has been increased awareness of microaggressions occurring during medical training. However, the prevalence and characteristics of microaggressions specifically in plastic surgery residency remain unknown. We aimed to fill this literature gap by conducting a nationwide survey to better understand and characterize microaggressions in plastic surgery training.

METHODS

A survey was distributed between March and May 2021 via the American Society of Plastic Surgeons Resident Representatives to 1014 integrated and 214 independent track plastic surgery trainees in the United States. Multiple Pearson's chi-square of independence and Fisher exact tests evaluated comparisons of microaggressions by sex, race, Hispanic origin, sexual orientation, and year in training. A multivariate regression analysis assessed associations between variables.

RESULTS

One hundred twenty-five participants responded to the survey (response rate: 10.2%). Of those who responded, 68.8% had experienced microaggressions in the past year. Female trainees experienced microaggressions more frequently than male trainees (P < 0.05). Asian trainees had higher odds to be a target of microaggressions compared with White trainees (P = 0.013). Nonheterosexual trainees were more likely to have experienced microaggressions compared with heterosexual trainees (P < 0.05). Independent trainees were more likely to experience microaggressions than PGY 1-2 and 3-4 integrated residents (P < 0.05).

CONCLUSIONS

Approximately seven in every 10 trainees stated that they experienced microaggressions in the past year. Females, racial minorities, sexual minorities, and independent trainees had higher odds of reporting that they experienced microaggressions. Further studies are needed to assess the implementation of strategies that address this problem to resolve inequities.

Current challenges for women in orthopaedics

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The 'Hidden Curriculum' is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective. Cite this article: Bone Jt Open 2021;2-10:893-899.

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

This study was undertaken to update reports from 2004 to 2005 through 2008 to 2009, and 2009 to 2010 through 2013 to 2014, including 5 additional years of GME Track data. Our hypothesis is there have been no significant changes during the past 5 years in the distribution of Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics residency programs that train female residents, compared with the previous 10 years.

Methods

Data for ACGME-accredited orthopaedics residency training programs in the United States were analyzed for 5 consecutive academic years (2014-2015 through 2018-2019). Programs were classified as having no women, 1 woman, 2 women, or greater than 2 women in training. Programs were analyzed for percentage of female residents and classified as having above the national average (>20%), similar to the national average (between 10 and 20%), or below the national average (<10%).

Results

Analysis of the original 5 years (2004-2009) compared with the most recent data (2014-2019) demonstrated a statistically significant improvement in the number of programs training women (p < 0.001). From 2004 to 2009 to 2014 to 2019, the absolute number and percent of female trainees have increased (p < 0.001). Similar analysis of the middle 5 years (2009-2014) compared with the most recent 5 years (2014-2019) did not demonstrate a statistically significant change (p = 0.12). From 2014 to 2019, residency programs in the United States continue to train women at unequal rates: 37 programs had no female trainees, while 53 programs had >20% female trainees during at least one of these 5 years.

Conclusions

Female medical students continue to pursue orthopaedics at rates lagging behind all other surgical specialties. Not all residency programs train women at equal rates. If the rate of training of female residents over the past 15 years were projected over time, we would not achieve 30% women within orthopaedics residency training programs until approximately 2060.

Level of Evidence

III.