If we really want to improve gender equity and increase the number of women in orthopaedic surgery, we must devise plans and execute them at the local, state, and federal levels. We must continue to expose young women to orthopaedic surgery and encourage and mentor them, but that does not address the current lack of women in orthopaedics or the financial cost of becoming an orthopaedic surgeon.

Diversity is important—you’ve heard it before, and you may even be actively addressing the issue. But gender inequity continues to be a stark reality for orthopaedic surgery. In the United States, women constitute approximately 51 percent of the population and 49 percent of the total workforce. However, of the 29,613 orthopaedic surgeons in the most recent AAOS survey, 6.5 percent were women, with just 0.1 percent choosing not to identify their gender. On a more positive note, 14.8 percent of candidate members are female.

In contrast, there are now more women in medical school than men. Yet there are still orthopaedic residency positions that have never been held by a woman. Women represent only about 14 percent of orthopaedic trainees. At the present rate of growth, it would take about 85 years to have 30 percent representation by female trainees, the amount at which diversity is noted to have an impact. The Department of Labor classifies jobs as “traditionally female” or “traditionally male.” Orthopaedics shares its low percentage (4.5–5.7 percent) with occupations such as machinists, welders, and firefighters. Occupations such as commercial airline pilots flying large, transoceanic jets and Fortune 500 CEOs also are well less than 10 percent female.

The impact of diversity

Why does diversity matter? The positive impact of diversity was well-stated by Janet Yellen, then-chair of the Board of Governors of the Federal Reserve System, at a conference of Brown University: “It is often said that we should welcome women’s presence in the workplace because it allows us to capitalize on the talents of our entire population, and this is certainly true. But it is also good business. A number of studies on how groups perform indicate that workforces that vary on dimensions such as gender, race, and ethnicity produce better decision-making processes and better outcomes.”

AAOS actively supports diversity and cultural competency within orthopaedics. The Diversity Advisory Board (DAB) and the Women’s Advisory Board (now incorporated into the DAB) have multiple initiatives for female patients. The DAB hosts symposia at the AAOS Annual Meeting to promote medical students’ interest in orthopaedics and guide them through the residency application process. Through its Office of Government Relations (OGR), AAOS has successfully advocated for increased funding for research into sex differences in musculoskeletal health, as well as research that includes diverse populations. Importantly, in a letter to the House of Representatives Energy and Commerce Committee, AAOS has urged Congress to engage underrepresented minority students and encourage them to enter healthcare professions and medical schools.

Legislative efforts

In April, AAOS agreed to cosponsor the Resident Physician Shortage Reduction Act of 2019, joining more than 65 other medical and surgical associations and specialty societies. The bipartisan legislation aims to provide increased Medicare support for graduate medical education (GME). In 2016, there was a funding shortfall from Medicare of about $84 billion. Worse yet, by 2030, there will be a projected shortfall of anywhere between 42,600 and 121,300 physicians in primary and specialty care. In March, Representatives Terri Sewell (D-Alaska) and John Katko (R-N.Y.) introduced a bipartisan bill into the House: H.R. 1763, the Resident Physician Shortage Reduction Act. You can individually express your support through your representative or the OGR.

Funding sources for GME can be federal or nonfederal (parent institution, philanthropy, gifts from industry). The government significantly funds orthopaedic GME through Medicare and supports training programs in the Veterans Health Administration. About 70 percent of all trainees rotate through a Veterans Affairs (VA) medical facility. However, there are expected funding cuts to Medicare- and Medicaid-sponsored GME. One approach to address this issue is to tie funding incentives to well-defined recruitment plans and participation of qualified women in orthopaedic GME. Programs receiving such incentives would be monitored, possibly by the Residency Review Committee, as would the American Board of Orthopaedic Surgery (ABOS) certification of all its residents and fellows. Complete financial support (free tuition) is already a reality for New York University School of Medicine and is planned for the new Kaiser Permanente Medical School in Pasadena, Calif.

Some states have addressed the financial burden of education with loan-forgiveness programs. The federal government and the VA have several loan-consolidation and repayment programs for its employees, including orthopaedic surgeons (Table 1).

Several orthopaedic organizations, including the Ruth Jackson Orthopaedic Society (RJOS), Perry Outreach Program, Nth Dimensions, and Orthopaedics in Action—part of the Perry Initiative—have also developed programs to expose women to and encourage them to consider careers in orthopaedic surgery. Medical students sponsored by RJOS, the Perry Outreach Program, and Nth Dimensions have an 80 percent or greater success rate of getting into orthopaedic residencies. Federal programs and incentives to encourage diversity in education have also been highly effective. For example, the federal government enacted Title IX in 1972 as an expansion and clarification of the Civil Rights Act of 1964, preventing discrimination on the basis of sex in any educational program receiving financial assistance.

Title IX provided more educational and activity opportunities for young women and resulted in increased participation in clubs, sports, and athletics. An unexpected benefit of those additional programs also arose. Economist Betsey Stevenson found that Title IX explained the 20 percent increase in education and 40 percent increase in employment for women aged 25–34 years. The growth was about 50 percent in the fields of law, dentistry, and medicine. She also noted that 80 percent of women who were managers at Fortune 500 companies had participated in sports. The effects of Title IX on orthopaedic surgery have not been documented with research. However, as a sports medicine orthopaedic surgeon, anecdotally, I have observed a higher percentage of women in orthopaedics who have participated in sports, dance, or organized physical activity.

Since Title IX, other federal programs have been established to promote gender equity in science and other related fields. President Barack Obama initiated two programs in 2009, and President Donald Trump more recently endorsed a House resolution requiring NASA to encourage women and girls to study STEM (science, technology, engineering, and math) and pursue careers in aerospace. As a result, NASA has been actively promoting increased participation of underrepresented groups in the field (Table 2). Universities, particularly those with medical schools and orthopaedic surgery training programs, may consider developing similar models.

Still, there’s work to do …

Ruth Jackson became an ABOS Diplomate in 1937—the first female orthopaedic surgeon to do so, which then qualified her to be the first female member of AAOS. Now, 86 years later, Kristy L. Weber, MD, is the Academy’s first female president. We are proud of Dr. Weber for her accomplishments and of AAOS for this milestone. However, we cannot forget that we still have the lowest percentage of women in any surgical specialty. We need to work together, continuing our focused efforts and adding new initiatives.

We can benefit from initiatives outside orthopaedics that have successfully addressed diversity and inclusion. Progress should start with a diversity champion and evaluation of each situation. The next steps include developing an action plan with accountability and oversight. We need women in the pipeline, and we need to treat them fairly and appropriately—this includes pay equity. For example, my undergraduate alma mater, Brown University, has a very detailed and closely followed goal of inclusion and diversity. Former RJOS President Claudette Lajam, MD, of New York University Langone Health, encouraged us to “Select Her, Elect Her, Promote Her” during her RJOS presidential speech in 2017. This is a good start for all levels of qualified female individuals already in orthopaedics. However, we have a responsibility to get qualified women in orthopaedic residencies.

Additional steps at multiple levels are required to promote and support diversity, and now is the time. If we really want to improve gender diversity and increase the number of women in orthopaedic surgery, we need to do more. We are orthopaedic surgeons. We fix things, and we can fix this, too. What will you do?

Marlene DeMaio, MD, is president of RJOS. Her academic affiliation is in the Department of Orthopaedic Surgery in the Perelman School of Medicine at the University of Pennsylvania, and she is on staff at the CPL Michael Crescenz VA in Philadelphia.

References:

1. American Medical Association: AMA Builds on Efforts to Expand Funding for Graduate Medical Education. Available at: https://www.ama-assn.org/press-center/press-releases/ama-builds-efforts-expand-funding-graduate-medical-education. Accessed May 15, 2019.
2. American Medical Association: The Most Powerful Prescription? A Well-trained Physician. Available at: https://savegme.org. Accessed May 3, 2019.
3. Association of American Medical Colleges: Preserve Medicare Support for Physician Training. Available at: https://www.aamc.org/download/262676/data/gmefactsheet.pdf. Accessed May 3, 2019.
4. AAOS: 2015 Orthopaedic Census Report. Available at: https://www.aaos.org/downloadasset.aspx?id=6442452323. Accessed May 15, 2019.
5. AAOS: Position Statement: The Financing of Graduate Medical Education. Available at: https://aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/position/1109%20The%20Financing%20of%20Graduate%20Medical%20Education.pdf. Accessed May 3, 2019.
6. Brown University: Office of Institutional Equity and Diversity Action Plans. Available at: https://www.brown.edu/about/administration/institutional-diversity/action-plans. Accessed May 3, 2019.
7. Congress.gov: H.R.1763—Resident Physician Shortage Reduction Act of 2019. Available at: https://www.congress.gov/bill/116th-congress/house-bill/1763?q=%7B%22search%22%3A%5B%22H.R.478%22%5D%7D. Accessed May 3, 2019.
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10. NASA: NASA STEM Engagement and Education Assets and Expertise. Available at: https://www.nasa.gov/education/partnerships/stem-engagement-assets-expertise.html. Accessed May 3, 2019.
11. NASA: Diversity and Inclusion Leadership. Available at: https://missionstem.nasa.gov/diversity-inclusion-leadrshp-topic02.html. Accessed May 3, 2019.
12. Congress.gov: S.808—Sports Medicine Licensure Clarity Act of 2017. Available at: https://www.congress.gov/bill/115th-congress/senate-bill/808. Accessed May 3, 2019.
13. Stevenson B: Beyond the Classroom: Using Title IX to Measure the Return to High School Sports. Available at: https://repository.upenn.edu/cgi/viewcontent.cgi?article=1017&context=psc_working_papers. Accessed May 3, 2019.
14. Yellen JL: So We All Can Succeed: 125 Years of Women’s Participation in the Economy. Available at: https://www.federalreserve.gov/newsevents/speech/yellen20170505a.htm. Accessed May 3, 2019.